Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
Angela Carpos
All Responded
2024-0211
22 Apr 2024
MiHomecare
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.
Action Planned
(AI summary)
MiHomecare is updating its training on choking/aspiration risks, to be released by the end of July, including a "Talking Head" discussion and updated prompt card via their new CCH Connect app. They are also reviewing care planning tools to specifically reference aspiration risks.
Alan Soane
All Responded
2024-0180
2 Apr 2024
Department of Health and Social Care
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.
Noted
(AI summary)
NHS England references the Long-Term Workforce Plan and actions to increase domestic education, training, and recruitment, as well as improve culture and retention. The response also highlights the use of AI and investment in pathology and imaging networks to increase productivity. The Department acknowledges the concerns about Consultant Histopathologist shortages and refers to NHS England's response. It cites the NHS Long Term Workforce Plan's goals to increase medical school places and grow the NHS workforce, and notes the increasing number of histopathology consultants and trainees.
Rose Hollingworth
All Responded
2024-0150
Care Quality Commission
Home Dot Care Limited
Islington Social Services
Care Home Health related deaths
Concerns summary (AI summary)
The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for a vulnerable person.
Disputed
(AI summary)
HomeDot Care has implemented a sleeping protocol, enhanced staff training, fully transitioned to an electronic care recording system, and revised call management procedures. They also introduced a new daily communication system, mandated staff shadowing, updated policies, and committed to annual mock inspections. The CQC conducted a comprehensive inspection of HomeDotCare Limited, finding that the service had already implemented several risk mitigation actions, including individual fire risk assessments, a 'sleep protocol,' updated next-of-kin notification policies, and comprehensive staff training. First aid training was also arranged immediately after the inspection. Islington Council has submitted a 'Letter Before Claim for Judicial Review' challenging the coroner's decision to issue a PFD report against them, arguing procedural irregularity and seeking to have the report quashed against the Council. Islington Council describes its robust processes for monitoring care agency performance, including a dedicated contract management team and a recently updated provider audit approach to include resident and staff feedback. They also undertook a procurement exercise to reduce provider numbers to enhance quality and safety.
Sandra Senior
All Responded
2024-0124
4 Mar 2024
Camden Council
Suicide (from 2015)
Concerns summary (AI summary)
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Action Taken
(AI summary)
The council removed the latch and hook from the communal door, installed an extra "Fire Brigade" lock on the rooftop exit, and relies on daily checks by the caretaking service to secure doors and report faults.
Kazarie Dwaah-Lyder
All Responded
2024-0072
9 Feb 2024
British Association of Paediatric Surge…
Royal college of Paediatrics and Child …
Royal College of Radiologists
Child Death (from 2015)
Concerns summary (AI summary)
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial imaging.
Action Planned
(AI summary)
The RCR confirms that a paediatric radiologist has been appointed to a multi-professional group led by BAPS, which will consider developing guidance on swallowing non-radio opaque objects. BAPS is leading a multi-professional working group to consider a generic pathway for all Foreign Body Ingestion (FBI) in children, with more specific guidance for commonly reported hazardous FBs and those that may be minimally or non radio opaque (radiolucent) on plain X-ray. The RCPCH will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and for discussion with the RCPCH Clinical Quality in Practice group. They acknowledge the clinical working group set up by BAPS to look at guidance for button battery ingestion and suggest that the group consider the report.
Abdullah Popalzai
All Responded
2024-0066
5 Feb 2024
NHS England
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.
Action Planned
(AI summary)
NHS England is working to address issues with timely access to mental health beds for prisoners, focusing on increasing access to hospital beds pre-sentence, and is working to support local mental health systems to reduce pressure on inpatient services. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions.
REDACTED
All Responded
2024-0031
18 Jan 2024
London Fire Brigade
Suicide (from 2015)
Concerns summary (AI summary)
There was some delay in the attendance of LFB, and firefighters recognised that their ladders would not reach the roof of the flats and so called for an extended height ladder appliance; police were concerned that the extended height ladder appliance had not been requested from the outset.
Disputed
(AI summary)
The London Fire Brigade claims information from its personnel is incongruous with the coroner's report and requests further information to enable a proper response.
Nicholas Cork
All Responded
2024-0015
11 Jan 2024
Sapphire Independent Living
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.
Action Taken
(AI summary)
Sapphire has implemented several changes, including revisions to the 'At Risk' procedure, permanent night staff recruitment, shift pattern reviews to reduce burnout, and ongoing discussions with the London Borough of Camden regarding support needs for referrals.
Bernadette Faulkner
All Responded
2024-0008
4 Jan 2024
Energy UK
Ministry of Housing, Communities & Loca…
Other related deaths
Concerns summary (AI summary)
The electricity meter's excessive height and placement behind an inwardly opening door created a significant safety risk for access, compounded by the lack of industry standards for meter accessibility.
Noted
(AI summary)
Energy UK expresses condolences and notes that it does not represent all energy network companies. It outlines existing industry practices regarding meter placement, safety checks, and support for vulnerable customers, referencing Ofgem guidance. Ofgem introduced new rules in November 2023 restricting suppliers from involuntarily installing prepayment meters for specific vulnerable customers, and suppliers are now required to assess the safety of prepayment meters annually.
Bobby Lee
All Responded
2024-0007
4 Jan 2024
Product Safety and Standards
Other related deaths
Product related deaths
Concerns summary (AI summary)
A significant rise in fires from faulty e-bike/e-scooter lithium-ion batteries and unsuitable chargers, often from inferior conversion kits and unregulated online sales, highlights the lack of specific safety standards.
Action Planned
(AI summary)
The government is part of a taskforce to establish the root causes of e-bike fires. A British Standard is being developed for businesses to use within 12-18 months and the Warwick Manufacturing Group (WMG) expects to deliver their final report later this year. The government's response to the Product Safety Review is expected later this year.
Kimberley Liu
All Responded
2023-0544
21 Dec 2023
Department for Culture, Media and Sport
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Action Taken
(AI summary)
The MHRA addresses illegal sale of prescription medications, working with partners across government; the Online Safety Act will give powers to Ofcom to ensure platforms remove illegal content; a national near real time suspected suicide surveillance system was launched in November 2023.
Sarah Chappell
All Responded
2023-0523
7 Dec 2023
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Action Taken
(AI summary)
UCLH has strengthened its governance structures, appointed a second learning disability nurse, instigated a process to review all deaths of patients with learning disabilities, convened a weekly incident review group, and actively promoted Learning Disability Awareness Week.
Luke Whitelaw
All Responded
2023-0486
27 Nov 2023
Oxleas NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI summary)
Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Action Taken
(AI summary)
Oxleas NHS Foundation Trust updated its Acute Mental Health Patient Flow and Bed Management policy in December 2023, and introduced a single crisis assessment form on 22 January 2024. They also reinforced documentation standards and protected time for complex case discussions, with clinical leadership and psychology support.
Jennifer Whinney
All Responded
2023-0477
27 Nov 2023
Queens Hospital
Royal London Hospital
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Action Taken
(AI summary)
Barts Health NHS Trust has undertaken several actions to reduce line infections at the Royal London Hospital, including providing education and training sessions for multidisciplinary surgical staff, and updating IPC statutory and mandatory training. They are also in the process of re-writing the ANTT policy with the microbiology and Infection Prevent and Control (IPC) teams. Barking Havering and Redbridge University Hospitals NHS Trust has revised its policy for sending patient notes to external hospital visits, with the updated policy approved on 22 January 2024. The revised policy includes explicit responsibilities, a checklist, and a signature section for acknowledging receipt of notes.
Mohammed Akram
All Responded
2023-0474
27 Nov 2023
Barnet Enfield and Haringey Mental Heal…
Suicide (from 2015)
Concerns summary (AI summary)
A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Noted
(AI summary)
Barnet Enfield and Haringey Mental Health NHS Trust describes its usual procedures for when a client is not taking their medication as prescribed. They state that the expected standard is for the GP to be notified via email within 48 hours of the medical review when there are any changes to the client’s prescription or treatment plan.
Glenn Lockwood
All Responded
2023-0487
17 Nov 2023
Limehouse Practice
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Noted
(AI summary)
The response provides a summary of the inquest findings, including the deceased's medical history and the coroner's conclusion of a drug-related death. It notes that a report will be issued to the Limehouse Practice regarding medication prescribing and documentation practices. The Limehouse Practice will conduct SEA training for prescribers, review prescribing for patients at risk of dependence, document medication changes, and provide refresher training on EMIS prescribing function. They have contacted CGL/RESET for training and have improved internal communications.
Igor Szalapski
All Responded
2023-0445
13 Nov 2023
Depaul UK
Suicide (from 2015)
Concerns summary (AI summary)
Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training and a chaotic culture contributed to missed opportunities for intervention.
Action Planned
(AI summary)
DePaul UK outlines steps to ensure staff recognise warning signs as a deterioration in mental health, make continued escalation and referrals, and ensure staff are well inducted, trained, managed and supported, will also ensure that individual case reviews continue alongside wider organisational reviews following serious incidents.
Claire Homer
All Responded
2023-0448
10 Nov 2023
Camden and Islington NHS Foundation Tru…
Other related deaths
Concerns summary (AI summary)
The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Action Taken
(AI summary)
Barnet, Enfield and Haringey Mental Health Trust discussed out-of-office responses and escalation procedures with staff, issued a template for out-of-office replies, ensured voicemail messages follow the same practice, updated online information with duty mobile numbers, reiterated the need for clear doctor cover arrangements, and emphasised the importance of balancing service needs with leave requests and clear patient handovers.
Frances Newbury
All Responded
2023-0443
10 Nov 2023
London Ambulance Service NHS Trust
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights a missed opportunity for potentially life-saving intervention in opiate overdose cases.
Noted
(AI summary)
The London Ambulance Service conducted a clinical review, stating that naloxone was not mandated in this instance. They highlight existing support for naloxone administration and offer to discuss ongoing work to improve cardiac arrest survival in London.
Michael Hindes
All Responded
2023-0521
20 Oct 2023
South West London and St George’s Menta…
Suicide (from 2015)
Concerns summary (AI summary)
There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about his mental health.
Action Planned
(AI summary)
The Psychiatric Liaison Team will be changing their local protocols to strengthen prompts to help remind clinicians how best to approach the subject of sharing information with patients' families. The Trust will raise awareness of this area via a specific newsletter article issued to Trust staff by March 2024.
Trevor Bailey
All Responded
2023-0419
20 Oct 2023
Church Lane Surgery
Northwick Park Hospital
Other related deaths
Concerns summary (AI summary)
The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.
Noted
(AI summary)
Church Lane Surgery updated their patient history templates, provided training to staff on collecting and recording family history of IHD, and restructured the on-call system for the Duty doctor by adding un-booked telephone and face-to-face slots. London North West University Healthcare NHS Trust argues that the patient's management in the emergency department was appropriate based on national scoring and existing chest pain pathways and describes the introduction of an Emergency Assessment Unit designed to improve waiting times.
Amarjit Singh
All Responded
2023-0342
18 Sep 2023
HM Prison Pentonville
Practice Plus Group
State Custody related deaths
Concerns summary (AI summary)
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.
Action Taken
(AI summary)
HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and the HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023. Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures to ensure that custodial staff are also able to identify cell-sharing issues.
Riya Hirani
All Responded
2023-0339
15 Sep 2023
Department of Health and Social Care
NHS England
Child Death (from 2015)
Concerns summary (AI summary)
A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism for families to obtain a second medical opinion.
Action Taken
(AI summary)
Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs. Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs.
Nicholas Ledger
All Responded
2023-0314
31 Aug 2023
College of Policing
Metropolitan Police Service
Suicide (from 2015)
Concerns summary (AI summary)
The report refers to evidence from the investigating officer and an investigator from the Metropolitan Police’s Directorate of Professional Standards.
Action Planned
(AI summary)
The College of Policing outlines that updated statutory guidance, e-learning, and knowledge products have been released regarding pre-charge bail, and specific guidance on safeguarding those subject to RUI has been issued. It also highlights existing guidance on risk assessments for those released from custody, and custody training aimed at reducing the risks of post detention suicides. The Metropolitan Police Service plans to implement a new policy by April 2024 requiring a risk assessment to be completed by the OIC no earlier than fourteen days prior to issuing the PCR for suspects charged with a recordable offence. This assessment will be supervised by line management and form part of the PCR process.
Mizanur Rahman
All Responded
2023-0306
29 Aug 2023
Product Safety and Standards
Other related deaths
Product related deaths
Concerns summary (AI summary)
A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal runaway, and multiple deaths.
Action Taken
(AI summary)
The Office for Product Safety and Standards has engaged with the London Fire Brigade and Tower Hamlets Trading Standards, established a multi-disciplinary safety study, commissioned research into battery safety, and published consumer information on safe e-bike practices.