Inner South London

Coroner Area
Reports: 143 Earliest: Aug 2013 Latest: 1 Feb 2026

82% response rate (above 62% average).

Response Status
Responded 117 Historic 22 Pending 1
AI Classification
Action Taken 17%
Action Planned 42%
Noted 25%
Disputed 17%
Based on 12 classified responses
Top Categories
Hospital Death (Clinical Procedure… (56) Other related deaths (23) Community health care and emergenc… (17) Suicide (from 2015) (17) Child Death (from 2015) (15)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: +7 reports · +24pp response rate
vs national average: +60 reports · +20pp response rate
143 results
Simon Moss
Response Pending
2026-0052 1 Feb 2026
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) +1 more
Suicide (from 2015)
Concerns summary Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.
Sundeep Ghuman
Partially Responded
2025-0625 15 Dec 2025
HMP Belmarsh Ministry of Justice
State Custody related deaths
Concerns summary Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Action taken summary HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Joan Talbot
All Responded
2025-0569 11 Nov 2025
Chief Executive Officer Denmark Hill King’s College Hospital +4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Action taken summary Kings College Hospital NHS Trust has established a cross-Trust 'Documentation Quality Improvement Working Group' to improve the use of their EPIC record system. This group will define metrics, identif
Paula Doreen
All Responded
2025-0511 14 Oct 2025
Royal College of Physicians Medicine and Healthcare Product Regulat… Lewisham and Greenwich NHS Trust +2 more
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Action taken summary NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training
James Siddons
All Responded
2025-0051 30 Jan 2025
Mills Family Ltd London Borough of Bromley
Care Home Health related deaths
Concerns summary A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
Naomi Suleyman
Partially Responded
2025-0049 29 Jan 2025
London Borough of Lewisham Lewisham and Greenwich NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
Charlie Marriage
All Responded
2025-0048 24 Jan 2025
NHS England
Alcohol, drug and medication related deaths
Concerns summary Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency medication access.
Edward Barnard
Partially Responded
2024-0640 21 Nov 2024
Royal College of Veterinary Surgeons Veterinary Medicines Directorate
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and veterinary societies must examine preventive measures to curb access and prevent future deaths.
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
All Responded
2024-0628 15 Nov 2024
Department of Health and Social Care Care Quality Commission NHS England +1 more
Alcohol, drug and medication related deaths Child Death (from 2015)
Concerns summary A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.
Lacey Brookman
All Responded
2024-0612 8 Nov 2024
Royal College of General Practitioners Royal College of Radiologists Royal College of Surgeons +1 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.
Maria Kelly
All Responded
2024-0515 27 Sep 2024
North London Mental Health Partnership Gray’s Inn Road Medical Centre
Community health care and emergency services related deaths
Concerns summary Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.
Kasey Beech
All Responded
2024-0473 29 Aug 2024
Royal College of Emergency Medicine NHS England National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
Joshua Delaney
All Responded
2024-0189 8 Apr 2024
NHS England
Alcohol, drug and medication related deaths
Concerns summary GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.
Jacqueline Cobain
All Responded
2024-0163 25 Mar 2024
South London and Maudsley NHS Foundatio…
Railway related deaths Suicide (from 2015)
Concerns summary A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was no protocol to alert clinicians to review these urgent responses outside the standard timeframe.
Isabella Shere
All Responded
2024-0298 5 Mar 2024
OFCOM Department for Culture, Media and Sport Department for Culture +1 more
Child Death (from 2015) Suicide (from 2015)
Concerns summary Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for children.
Oliver Beswetherick
All Responded
2024-0097 21 Feb 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
All Responded
2023-0514 5 Dec 2023
UK Civil Aviation Authority
Child Death (from 2015) Other related deaths
Concerns summary A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.
Fraser Moore
Historic (No Identified Response)
2023-0497 4 Dec 2023
Network Rail Department for Transport
Railway related deaths
Concerns summary Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.
Manoel Santos
Partially Responded
2023-0361 3 Oct 2023
Practice Plus Group Ministry of Justice HM Prison and Probation Service +2 more
State Custody related deaths Suicide (from 2015)
Concerns summary Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
Isabela Suciu
Partially Responded
2023-0326 12 Sep 2023
Royal College of Paediatrics and Child … Queen Elizabeth Hospital Trust NHS England +1 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Juanita Nti
All Responded
2023-0301 18 Aug 2023
NHS England
Child Death (from 2015)
Concerns summary Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.
Shirley Ashelford
Partially Responded
2023-0297 17 Aug 2023
London Borough of Southwark Bureau Veritas UK Ltd Prism Medical UK Ltd +1 more
Other related deaths
Concerns summary Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared with the occupational therapy department, created significant safety gaps.
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023
HMP Thameside HM Inspectorate of Prisons Ministry of Justice +1 more
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Christian Tuvi
All Responded
2023-0239 10 Jul 2023
Department for Transport
Other related deaths
Concerns summary A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on temporary measures.
Tomas Ceida
Partially Responded
2023-0086Deceased 9 Mar 2023
London Fire Brigade Health & Safety Executive JHS Contracts +1 more
Other related deaths
Concerns summary Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding building safety. There is also a lack of clarity on fire safety responsibilities for contractors.