Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
Lauren Murdock
All Responded
2022-0104
Faculty of Sexual and Reproductive Heal…
Lathom Road Medical Centre
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved risk assessment.
Action Planned
(AI summary)
The FSRH is commencing a planned update to the UK MEC in 2022/2023 to improve content usability and is exploring the viability of an APP that could include a 'risk calculator' to support its guidelines. The medical centre has displayed a new sign instructing patients to submit BP readings, created a formal protocol for staff on monitoring and reporting readings, and will implement Accurx text message reminders for patients on combined hormonal contraceptives to recheck BP. The medical centre held a significant event analysis to discuss options for preventing missed blood pressure readings, including trying a new placement for the machine, establishing criteria for its use, and investigating a coin-slot system with the manufacturer.
Gary Ottway
Historic (No Identified Response)
2022-0087
18 Mar 2022
East London NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.
James Forryan
All Responded
2022-0086
18 Mar 2022
Minister for Care and Mental Health and…
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Action Taken
(AI summary)
The Department of Health and Social Care is taking steps to protect users online with the Online Safety Bill, working with stakeholders to remove harmful suicide and self-harm content. They are investing £57 million in suicide prevention through the NHS Long Term Plan, and provided £5.4 million to Voluntary, Community and Social Enterprise organisations.
Neil Hickman
Partially Responded
2022-0064
28 Feb 2022
East Kent Hospitals University NHS Foun…
Kent and Canterbury Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.
Action Taken
(AI summary)
The hospital has implemented a policy that all Myelodysplastic Syndrome patients undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured.
Martha Mills
All Responded
2022-0063
28 Feb 2022
King’s College Hospital NHS Foundation …
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.
Action Taken
(AI summary)
King's College Hospital outlines actions taken and planned following a serious incident investigation, including establishing regular meetings between departments, developing new care pathways, improving access to specialist services, and providing additional training. They also detail how ongoing actions will be monitored.
Van Tuyen
All Responded
2022-0058
22 Feb 2022
Barts Health NHS Trust
Department of Health and Social Care
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
Action Taken
(AI summary)
The Department of Health and Social Care highlights existing guidance and resources related to nasogastric tube misplacement, including a patient safety alert and eLearning materials. They also mention the HSIB investigation and the awarding of funding for research on patient safety, including the reduction of never events.
Ziggy Mitchell-Stagg
Historic (No Identified Response)
2021-0425
17 Dec 2021
Homerton University Hospital NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.
Khadija Ahmed
All Responded
2021-0410
2 Dec 2021
Swiss Cottage Special School
Other related deaths
Concerns summary (AI summary)
School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.
Action Taken
(AI summary)
Swiss Cottage School has organised Basic Life Support with CPR training for 70 members of staff, timetabled to every class across the school, delivered on 12th and 14th January 2022.
Berenice Bell
Partially Responded
2021-0404
22 Nov 2021
Department for Digital, Culture, Media …
Home Office
Joint Select Committee for the Draft On…
Mental Health related deaths
Product related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.
Action Planned
(AI summary)
The Department is taking steps to protect users online via the draft Online Safety Bill, which will require in-scope companies to remove illegal content that encourages or incites suicide. They are also considering Law Commission recommendations for new offences to address encouragement or assistance of self-harm online.
Joseph Martin
Historic (No Identified Response)
2021-0389
16 Nov 2021
Police Service of Northern Ireland Belf…
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.
Lorraine Karat
All Responded
2021-0364
29 Oct 2021
Clarion Housing Group
Alcohol, drug and medication related deaths
Other related deaths
Concerns summary (AI summary)
Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a significant fall risk in housing properties.
Action Planned
(AI summary)
Clarion Housing Group is informing tenants that access to flat roofs is unauthorised and unsafe and issuing guidance to staff to identify flat roofs where unauthorised access might occur. Additional measures such as window locks and restrictors can be installed where a risk of unauthorised access to a flat roof has been identified.
Freeda Glausiusz
All Responded
2023-0199
20 Oct 2021
East London NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI summary)
A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.
Action Taken
(AI summary)
East London NHS Foundation Trust has implemented changes to the Crisis Line, including a revised supervision structure, training for call handlers, and improved record-keeping. They have hired four new SI investigators to clear the backlog of reports and agreed to hire an additional solicitor to increase the Legal Affairs Team’s capacity.
Michael Jaggs
All Responded
2021-0333
6 Oct 2021
MedPure Healthcare
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.
Action Taken
(AI summary)
The agency has outsourced complaints to a clinical team, implemented a policy for reflective statements upon complaint, and can offer immediate additional training; they have also assisted the nurse in self-referring to the NMC.
Chimezie Daniels
All Responded
2021-0255
16 Jul 2021
Medicines and Healthcare products Regul…
NHS England
NHS Improvement
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.
Noted
(AI summary)
NHS England notes that the concerns raised relate to the design of medical devices and fall under the remit of the MHRA, but they have worked with the British Thoracic Society and continue to work with the Faculty for Intensive Care Medicine to develop guidance on alarm systems and breathing circuits. The MHRA states that the audible alarm system in the Philips Trilogy 202 device is based on an internationally recognised standard and that there is currently no evidence to indicate a wider safety concern. They are engaging with professional organizations to explore alarm prioritisation and have requested information from a patient safety incident database.
Alan Griffin
All Responded
2021-0243
Catholic Standards Safeguarding Agency
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. Significant delays in the safeguarding investigation were also identified.
Action Planned
(AI summary)
The Church of England has formed a Case Steering Group to oversee its response and is committed to undertaking a Lessons Learned Review to implement significant improvements in handling conduct and safeguarding concerns. The Catholic Safeguarding Standards Agency has reviewed evidence and is in the process of developing a formal Case Consultation Committee to offer expert advice on complex cases. Upon review completion, they plan to arrange events to share learning across Church bodies.
Stephen Walker
All Responded
2021-0254
12 Jul 2021
Royal Free Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No record indicated an abdominal examination was conducted, a medical review fixed, or a nasogastric tube passed; a registrar said the patient declined a nasogastric tube, but there was no record of this; nurses bleeped twice for a medical review, but there was no record of a review being undertaken or chased; and online medical records were confusing.
Action Taken
(AI summary)
The case was declared a serious incident and investigated; the report has been submitted to commissioners with an action plan. The hospital has launched a new electronic patient information system (EPR) and is reviewing processes for recording outcomes of Mortality and Morbidity meetings.
Henry Boddy
Partially Responded
2021-0227
2 Jul 2021
Fire and Communities, Ministry of Housi…
Home Office
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Noted
(AI summary)
The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of Safe and Well visits and safeguarding referrals.
Khairul Rahman
Partially Responded
2021-0226
2 Jul 2021
Head of Healthcare) and
HMP Pentonville
State Custody related deaths
Concerns summary (AI summary)
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Action Planned
(AI summary)
Practice Plus Group has begun a service improvement project to encourage the appropriate use of NEWS2 scoring and embedding this into practice, including a ‘Back to Basics’ workshop on ‘Identifying the Deteriorating Patient’ for the healthcare team at HMP Pentonville by 30th November 2021.
Angela Best
All Responded
2021-0194
4 Jun 2021
Ministry of Justice
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Action Taken
(AI summary)
The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes.
Macaulay Wilson
All Responded
2021-0146
7 May 2021
Lower Clapton Group Practice
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect care being provided by district nurses.
Action Taken
(AI summary)
The practice has implemented a system to highlight correspondence with instructions to wider clinical team members, included a copy of the original letter with onward referrals, and is undertaking an audit of patients with catheter products on prescriptions. They have also created an electronic template for patients with new indwelling catheters and an electronic alert to prompt checks when a patient is prescribed catheter products.
Gary Day
All Responded
2021-0107
13 Apr 2021
Moorfields Eye Hospital NHS Foundation …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.
Action Taken
(AI summary)
Moorfields Eye Hospital NHS Foundation Trust has completed an internal investigation, shared the report with the next of kin, and elected to not undertake further procedures of this nature due to lack of facilities for enhanced monitoring.
Ben O’Hara
Partially Responded
2021-0077
17 Mar 2021
Camden & Islington NHS Foundation Trust…
St Pancras Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.
Action Taken
(AI summary)
The Trust has developed a new post for a Senior Crisis Liaison Nurse to work between Personality Disorder and crisis services, appointed to in June 2021. Crisis teams have also been reminded that they may bring complex cases to the complex case panel/risk panel for discussion and support.
Paula Speirs
All Responded
2021-0064
4 Mar 2021
Weymouth Street Hospital
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.
Action Taken
(AI summary)
Phoenix Hospital Group has reviewed and revised policies/procedures at Weymouth Street Hospital, conducted root cause analysis meetings, scheduled a Managing a Deteriorating Patient workshop, and is highlighting the Coroner's concerns to nurses through regular briefings and a final reflection and learning session.
Grazyna Walczak
All Responded
2021-0063
4 Mar 2021
St Pancras Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
Action Planned
(AI summary)
The iCope service has reviewed its policy on contact with clients’ families and is implementing a new system reporting process to enable easier reporting and monitoring of 72-hour reports, including a training programme for divisional staff to support the implementation of the new system.
Cecilia Edwards
All Responded
2021-0049
22 Feb 2021
Whittington Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.
Action Planned
(AI summary)
Whittington Health is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, with regular audits to monitor compliance; the guidance will be ratified in August 2021. The service has reviewed its processes for private carer arrangements and will document agreed care plans with families in the electronic patient record.