Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
Amy Allan
All Responded
2019-0343
30 Sep 2019
Great Ormond Street Hospital NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Action Taken
(AI summary)
Great Ormond Street Hospital has improved the spinal surgery pathway with intensive care and ECMO support, including ensuring relevant MDT members are involved in decisions, creating consultant-level handovers to ICU, and creating spinal CNS high-risk patient reminders. They also established a clear process for escalation to the ECMO team.
Patrick Bolster
All Responded
2019-0314
25 Sep 2019
Network Rail
Railway related deaths
Concerns summary (AI summary)
A broken fence was not inspected for over two years due to dense vegetation blocking the view, inspectors failed to view the fence from the public side, and system failures led to the track engineer and internal auditors not seeing evidence of the failure to inspect the fence.
Action Planned
(AI summary)
Network Rail is issuing a National Safety Bulletin to Off Track teams, completing a special topic audit on compliance with the new boundary inspection standard, and reviewing national data. These actions are tracked via the Network Rail CMO-Compliance Tracked Action system.
Ben Haddon-Cave
All Responded
2019-0314-wp26824
25 Sep 2019
Network Rail
Railway related deaths
Concerns summary (AI summary)
Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Action Planned
(AI summary)
• A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections.
• The National Safety Bulletin will reference the key learning from this tragic event, specifically stating that where a team is unable to view a boundary fence from trackside due to vegetation, they must view the fence from the other (public) side.
• The National Safety Bulletin will also state that if the fence cannot be viewed from either side, the team must record this and escalate it to their supervisor.
Tony Dunne
All Responded
2019-0265
20 Aug 2019
East London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to jump, missing a critical intervention opportunity.
Action Planned
(AI summary)
The City and Hackney HTT will provide additional training during its away days scheduled for 4 and 5 December 2019, including reviewing the core competencies and standard of risk assessment required by clinicians and reinforcing the standard of medical record taking. Additionally, the City and Hackney HTT will be rolling out a new protocol on checking outstanding work following sickness.
Fern-Marie Choya
Historic (No Identified Response)
2019-0281
31 Jul 2019
London Ambulance Service NHS Trust
Whittington Health NHS Trust
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical treatment.
Alexander Boamah
All Responded
2019-0232
5 Jul 2019
Department for Work and Pensions
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of illicit substance misuse.
Action Planned
(AI summary)
The DWP is currently reviewing its safeguarding policy and guidance with the aim of strengthening existing procedures. The review will consider communication channels between the Department and treating clinicians and is scheduled to provide a revised policy and guidance in September 2019.
Tien Phung
Partially Responded
2019-0204
19 Jun 2019
British Transplantation Society
NHS Blood and Transplant
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, risking severe progression.
Action Planned
(AI summary)
NHSBT and BTS will write to SaBTO to formally advise them of this case and ask for a clear position on donor screening. BTS will discuss with their standards committee about any future guidance on Strongyloides infection in transplantation and NHSBT will write to Transplant Centre Directors to inform them anonymously of this case for awareness and include information on this infection as part of shared learning in NHSBTs Medical Bulletin and Cautionary Tales.
Karanbir Cheema
All Responded
2019-0161
10 May 2019
British Society for Allergy and Clinica…
Department for Education
Department of Health and Social Care
+5 more
Child Death (from 2015)
Concerns summary (AI summary)
The report details issues at the deceased's school, including a patchy understanding of allergies, unchecked care plans and medical boxes, out-of-date medication, non-standardised allergy action plans, and a failure to send allergy action plans to the school.
Action Planned
(AI summary)
The London Ambulance Service raised the PFD regarding EpiPen usage with the UK Clinical Focus Group for IAED-MPDS and with the Executive Director of MPDS and awaits their conclusion. The Chief Medical Officer has shared the PFD with the Chair for The National Ambulance Service Medical Directors for their consideration. The Trust will review allergy action plans and injection techniques with children and carers in the clinic. They have added the additional process of posting or emailing each allergy plan to the school in question and advised the relevant department that before a clinic list is cancelled, the clinician is to review for time-critical appointments. Changes have been made so two adrenaline auto-injectors are kept with the child and two at school.
Steffan Kuenzel
All Responded
2019-0002
29 Apr 2019
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.
Noted
(AI summary)
Barts Health NHS Trust acknowledges the seriousness of alcohol addiction and states that their public health consultant is working on improved health care packages for alcoholic patients, following successful packages for smokers.
Brian Goodman
All Responded
2019-0129A
17 Apr 2019
One Hosing Group
Community health care and emergency services related deaths
Concerns summary (AI summary)
A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.
Action Planned
(AI summary)
One Housing will work with their property services to explore alternative fire door closures in high-risk schemes and implement ASIST suicide intervention skills training for staff.
Ozan Allen
All Responded
2019-0197
1 Apr 2019
Transport for London
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of collisions.
Action Planned
(AI summary)
TfL is considering adjustments to the junction design and plans to publish a consultation report by October 2019, with construction potentially starting in winter 2019/20. They are also proposing a reduced speed limit of 20mph and investigating measures on the A11 Mile End Road approaches, with completion planned by 2024.
Tony Goodridge
Historic (No Identified Response)
2019-0172
28 Mar 2019
London Borough of Camden
Other related deaths
Concerns summary (AI summary)
The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.
John Pearce
All Responded
2019-0068
25 Feb 2019
Central and North West London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.
Action Taken
(AI summary)
The Trust acknowledged failures in care and has re-trained staff in wound management, including the use of the NEWS2 tool for deteriorating patients. They will also conduct a 3-month action plan to ensure improvements are embedded, including improved communication and escalation procedures with specialist services and GPs.
Jack Hubbard
Historic (No Identified Response)
2019-0033
28 Jan 2019
Egg London Nightclub
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.
Arun Viswambaran
Historic (No Identified Response)
2019-0487
24 Jan 2019
North East London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
Tyrone Givans
Partially Responded
2019-0028
23 Jan 2019
Care UK
HMP Pentonville
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary)
Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.
Action Planned
(AI summary)
Care UK provides healthcare services at HMP Pentonville, and they are committed to working with partner agencies in tackling illicit substance supply and trading. A new Health and Wellbeing model was implemented on May 14, 2018, acting as an additional safety net for patients coming into prison. HMPPS published a national Prison Drugs Strategy in April and is revising and republishing its local drug strategy. A new equality policy framework with guidance on reasonable adjustments will be published in June, and a resource tool is being developed to digitally collect more personalized information from prisoners, aiming for implementation in June/July 2019.
Norman Pirie
All Responded
2019-0030
18 Jan 2019
Royal London Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.
Action Planned
(AI summary)
The Trust will implement enhanced MDT review of device selection including non-IFU treatments, document the decision in the patient's record, and inform the patient and GP about treatment options.
Agnes Lambert
All Responded
2018-0410
17 Dec 2018
Camden & Islington NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Action Planned
(AI summary)
The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge whether a formal hearing is required, and the refreshed policy is expected to be complete in March 2019.
Paliben Dullabh
All Responded
11 Dec 2018
Homerton Healthcare NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.
1 response
from paliben dullabh
Dawn Gill
All Responded
2018-0354
16 Nov 2018
Royal London Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the drug chart went missing. A search of the patient's room also did not detect her body under clothing on the floor until hours later.
Action Taken
(AI summary)
Barts Health NHS Trust is reminding nursing teams about documenting suspected illicit drug use in care plans and handovers. They have reviewed the missing person policy and reminded nursing teams about the risks of making assumptions.
Rosario Cordero-Sanz
All Responded
2018-0307
29 Oct 2018
Metropolitan Police Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical information meant a high-risk patient's status was missed, delaying appropriate action.
Action Taken
(AI summary)
The MPS purchased and distributed 100 tablet devices for MSC officers in September 2018 and completed the rollout in November 2018. Local learning was implemented for MSC officers and a CAD operator regarding communication failures.
Catherine Gibbon
Historic (No Identified Response)
2018-0317
24 Oct 2018
DW Fitness First
UK Active
Other related deaths
Concerns summary (AI summary)
Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a broken camera, lack of emergency alarms/communication, and lapsed first aid certifications at the gym.
Colin Griffiths
All Responded
2018-0295
4 Sep 2018
Masta Limited
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of patient records made by nurses.
Action Taken
(AI summary)
The MHRA considered the adequacy of statutory information for prescribers and patients on the safe use of yellow fever vaccine. They intend to issue a further reminder about the risks of live vaccines in immunocompromised patients via its Drug Safety Update (DSU) bulletin, and has added the report of Mr Griffiths' adverse reaction to Yellow Fever vaccine to the MHRA's Yellow Card database. MASTA has re-evaluated policies and systems, introduced a tick box questionnaire for patients, implemented face-to-face audits at clinics, and observed/documented post-injection advice. They also plan to re-audit clinics of concern and are calling for other Yellow Fever Vaccination Centres to adopt similar preventative measures.
David Sweeney
Historic (No Identified Response)
19 Aug 2018
London Ambulance Service NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary)
A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising concerns about the handling of calls regarding unconscious patients.
Flora Baber
All Responded
2018-0229
13 Aug 2018
Adelaide Medical Centre
Compton Lodge Care Home
Royal Free Hospital NHS Trust
Care Home Health related deaths
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient did not always receive appropriately pureed food or assistance to eat, and there was a delay in referring her to the speech and language team. Staff also discouraged her from using the toilet, and her opioid sensitivity was not consistently recorded.
Action Taken
(AI summary)
• The practice determined that sensitivities to opioid drugs could be recorded in the notes on a case-by-case basis, requiring clinical judgement.
• A meeting was held to discuss how the sensitivity to opioids could have been coded appropriately in the GP notes.
• A meeting was held with a Royal Free Geriatrician and Compton Lodge Dept Care Home Manager to share Adelaide’s learning and see how this may support recording at the Royal Free and Compton Lodge. • The Trust wrote to the family to seek further information regarding the issues raised during the Inquest.
• The patient was cared for throughout her stay in 8 West in what is known as a “high bay”, meaning that staff were present in the bay at all times to supervise the patients.
• Water is normally kept on the patients’ bedside tables.