Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
Edward Gascoigne
All Responded
2015-0401
7 Oct 2015
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary)
The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Noted
(AI summary)
The Department of Health describes the Summary Care Record (SCR) system and planned enhancements, stating that it is designed to improve access to patients’ GP records.
Dean Joseph
All Responded
2015-0319
12 Aug 2015
Metropolitan Police Service
Police related deaths
Concerns summary (AI summary)
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Action Taken
(AI summary)
The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers when giving their accounts, and the PIM is trained to record his or her decision and reasoning.
Darren Neville
All Responded
2015-0220
10 Jun 2015
Metropolitan Police Service
Police related deaths
Concerns summary (AI summary)
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Noted
(AI summary)
The Metropolitan Police acknowledge the concerns and detail the challenges of responding to Acute Behavioural Disorder (ABD) incidents, highlighting existing training and the need for officers to act decisively. They assert that measures have been introduced since 2013 and in response to the death to refine training and equip officers.
Mark Daniels
All Responded
2015-0208
1 Jun 2015
Camden and Islington NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Action Taken
(AI summary)
Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all Crisis Teams and Crisis Houses and a plan to monitor their implementation.
Oliver Asante-Yeboah
All Responded
2015-0201
27 May 2015
Care Quality Commission
Child Death (from 2015)
Concerns summary (AI summary)
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Noted
(AI summary)
The CQC states it has no regulatory remit over non-therapeutic circumcisions performed for religious purposes by non-healthcare professionals, as the regulations would require amendment by the Secretary of State. The Department of Health acknowledges concerns about non-medical settings for male circumcision and notes that a change in legislation would require consultation. They will copy the letter to clinical leads of CCGs in England to highlight the case and reiterate the advice that circumcision should be carried out by a regulated healthcare professional.
Keith Gallimore
All Responded
2015-0184
11 May 2015
Camden and Islington NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Action Planned
(AI summary)
IAPTUS training will be provided to a small number of front-line staff in the Acute Division to enable routine checks on all new patients against the IAPTUS system, expected to take place at the end of September.
Rasharn Williams
All Responded
2015-0168
29 Apr 2015
Berger Primary School
Child Death (from 2015)
Other related deaths
Concerns summary (AI summary)
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.
Action Taken
(AI summary)
Berger Primary School has reviewed care plans, will refer unclear emergency provisions to school nurse/consultant, and amended its policy to ensure clarity in emergency situations. They will place photos and summaries of children with severe medical conditions in the staff and medical rooms.
Tamara Holboll
All Responded
2015-0171
27 Apr 2015
Camden & Islington NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.
Action Taken
(AI summary)
Camden and Islington NHS Trust has amended the action plan template and revised guidance for writing recommendations, adding an action row to prompt authors to write an action for each recommendation. They are also reviewing and improving their Serious Incidents processes.
Sabrina Stevenson
All Responded
2015-0126
30 Mar 2015
College of Paramedics
London Ambulance Service NHS Trust
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
Action Planned
(AI summary)
The College of Paramedics commits to writing to NHS ambulance services and HEIs to offer assistance in recruiting paramedics, advising them of revised Paramedic Curriculum Guidance. It will also advise the JRCALC on the recommendation made by the Consultant Gynaecologist and the issue of triage tools. London Ambulance Service secured additional investment of £27.2m to improve response times, increase staffing, and improve productivity and are on track to recruit 850 staff in 2015/16. The LAS has also updated its Serious Incident Policy to ensure staff receive feedback from investigations. NHS England details actions taken with the LAS, including weekly performance reviews, additional funding of £27.2m for 2015/16 to increase staffing and capacity, and improve ambulance response times, with a goal to meet national standards by September 2015. They also cite initiatives to reduce unnecessary vehicle dispatches.
John Dack
All Responded
2015-0151
19 Feb 2015
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.
Noted
(AI summary)
Barts Health NHS Trust investigated the incident and has reminded staff of the importance of accurately changing patient details and the consequences of not doing so. They note that the patient did know about the follow-up appointment.
Andrew Frost
All Responded
2015-0119
12 Feb 2015
Killick Street Health Centre
Community health care and emergency services related deaths
Concerns summary (AI summary)
A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.
Action Planned
(AI summary)
The health centre met with the Crisis Team to discuss service provision and will hold meetings every 6 months to discuss the Crisis Team service and individual clients.
Rufjan Bibi
All Responded
2015-0053
11 Feb 2015
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.
Action Taken
(AI summary)
The Trust implemented intentional rounding and documentation audits, and carries out observations of care. A doctor received training on obtaining consultant reviews, and the case was discussed at a morbidity and mortality meeting.
Andrew Aitken
All Responded
2014-0561
15 Dec 2014
Barts NHS Trust
East London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Action Planned
(AI summary)
The Trust investigated the concerns, interviewing staff and reviewing medical records, finding that tablets left at the bedside were intended to be destroyed by a pharmacist and were locked in a medicine cupboard. The Trust booked and paid for a taxi to take the deceased home after discharge, as he had no clothes. The Trust will ensure staff are aware that patients can self-refer to the RAID service and is considering how to best communicate this information to all staff working in Tower Hamlets. The Trust will also ensure clinical discussions from daily clinical meetings are recorded in patient medical records and that junior doctors discuss patients seen during liaison duties in consultant supervision.
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
All Responded
2014-0520
25 Nov 2014
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Action Planned
(AI summary)
NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
William Davies
All Responded
2014-0475
5 Nov 2014
Care UK Limited
State Custody related deaths
Concerns summary (AI summary)
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.
Action Taken
(AI summary)
Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National Medical Director clarified GPs' responsibilities regarding verifying death, and guidance/training is being developed to support decision-making in unexpected collapse or death cases.
Satheeskumar Mahatheaven
All Responded
2014-0412
19 Sep 2014
HMP Pentonville
State Custody related deaths
Concerns summary (AI summary)
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Action Taken
(AI summary)
HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested in all cases with health concerns, and all new healthcare staff are shown how to use the SystmOne electronic record system correctly.
Irshad Ali
All Responded
2014-0387
29 Aug 2014
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
Action Taken
(AI summary)
The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds.
Noleen McPharlane
All Responded
2014-0370
7 Aug 2014
Camden and Islington NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.
Action Planned
(AI summary)
The Trust updated its clinical risk assessment and management policy in September 2014. All clinical staff will be instructed to discuss methods of self-harm with service users and care plans will be set to prevent self-harming practices by November 2014.
Harold de Mello
All Responded
2014-0449
7 Jul 2014
Tower Hamlets Social Services
Community health care and emergency services related deaths
Concerns summary (AI summary)
A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.
Action Planned
(AI summary)
Tower Hamlets Social Services has convened a Case Review meeting and commissioned an internal management review. They are developing a risk analysis tool, introducing an eco-mapping tool, and scheduling targeted training, with further changes planned due to the implementation of the Care Act 2015.
Ralph Goslin
All Responded
2014-0282
25 Jun 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Action Taken
(AI summary)
The trust has commissioned specialist epilepsy training from the National Neurological Commissioning Support Unit, working with the National Epilepsy Society, across inpatient and residential services. The process for sharing recommendations has been changed to ensure follow-up and written communication with all members of the group.
Stephen Ward
All Responded
2014-0248
29 May 2014
Camden & Islington NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Noted
(AI summary)
Response is blank.
Gregg O’Reilly
All Responded
2014-0221
19 May 2014
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Action Planned
(AI summary)
Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board (meeting August 2014), and launching an education strategy to identify deteriorating patients.
Peter Brookes
All Responded
2014-0205
7 May 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Action Taken
(AI summary)
The Trust has a policy that all new patients should have their medication reconciliation completed within 24 hours and are looking to achieve 100% compliance. It also has measures in place to minimise the risk of dispensing errors including double checks, separate storage of similar drugs and mandatory reporting of errors.
Francis Golding
All Responded
2014-0136
14 Apr 2014
Camden Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised safety improvements.
Action Planned
(AI summary)
Camden Council will issue a brief to traffic consultants by the end of May 2014 to invite tenders for traffic signal modelling in the Holborn area, including the Southampton Row/Vernon Place junction, with consultants expected to be appointed in mid-June 2014.
Eric Matthews
All Responded
2014-0151
4 Apr 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Noted
(AI summary)
The Trust investigated a survey of 'cot deaths' in unusual scenarios but it did not prove feasible due to data protection and consent issues. They suggest coroners liaise with clinicians working on sudden infant death and release data from existing child death reviews.