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 27%
Action Planned 45%
Noted 20%
Disputed 8%
Based on 49 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
Clear 80 results
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 NHS England Medicine and Healthcare Product Regulat… +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
London Borough of Bromley Mills Family Ltd
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.
Action taken summary The Council has held discussions with staff regarding timely sharing of safeguarding concerns and put processes in place, including Consultant Lead Practitioners for practice support. They also plan t
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.
Action taken summary NHS England has instigated a Medicines Safety Improvement Programme and reviewed/updated the 111 algorithm for medication requests to improve access to "Time Critical Medicines." A new clinical guidel
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
All Responded
2024-0628 15 Nov 2024
NHS England Department of Health and Social Care Care Quality Commission +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.
Action taken summary NHS England has established a cross-organisational working group to enhance oversight and information sharing for Section 10 exempt entities. They plan to publish revised guidance with clearer reporti
Lacey Brookman
All Responded
2024-0612 8 Nov 2024
Royal College of Surgeons Royal College of Paediatricians and Chi… Royal College of Radiologists +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.
Action taken summary The Royal College of Radiologists acknowledges the diagnostic challenges of retrocaecal appendicitis and the limitations posed by radiology workforce shortages and availability of out-of-hours ultraso
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.
Action taken summary Grays Inn Medical Group agrees with the coroner's concerns and commits to endeavour to clarify if things have been sorted in future, and if not, they will possibly call Adult …
Kasey Beech
All Responded
2024-0473 29 Aug 2024
National Institute for Health and Care … Royal College of Emergency Medicine NHS England
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.
Action taken summary NHS England states they do not endorse a particular STREAMing model nationally and, following a review, contends that Medway Maritime Hospital's STREAMing pathway does not unduly prioritise chest pain
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.
Action taken summary NHS England plans to issue communications to GPs reiterating that Propranolol is not recommended for anxiety by NICE and highlighting the risks of its administration. They are also engaging with …
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.
Action taken summary South London and Maudsley NHS Foundation Trust explicitly states they will not implement a new protocol to automatically follow up on cancelled appointments with concerning questionnaire responses. Th
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.
Action taken summary The Department for Science, Innovation and Technology confirms the Online Safety Act (OSA) is in place to address concerns about harmful online content. The OSA will mandate tech companies to …
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.
Action taken summary NHS England notes the concern and explains that existing mechanisms, such as the 'Service Finder Tool' and the NHS website directory, already provide health and social care professionals with contact
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.
Action taken summary The CAA plans to publish relevant guidance and related material on its website by July 2024, and a Safety Sense Leaflet on mountain flying by December 2024. They will also …
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.
Action taken summary NHS England states national work is underway by paediatric experts to standardize oral liquid strengths, develop national guidelines, and improve GP prescribing systems, including through a newly esta
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023
HM Inspectorate of Prisons HMP Thameside 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.
Action taken summary HM Inspectorate of Prisons clarifies its independent inspection remit, noting that the information from the PFD report regarding HMP Thameside will be used in its ongoing risk assessment for future …
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.
Nathan Forrester
All Responded
2023-0035Deceased 31 Jan 2023
HM Prison and Probation Service NHS England
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
Liridon Saliuka
All Responded
2022-0355 8 Nov 2022
Oxleas NHS Trust HMP Belmarsh
State Custody related deaths Suicide (from 2015)
Concerns summary There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Daniel O’Sullivan
All Responded
2022-0330 21 Oct 2022
Department of Health and Social Care Central and North West London NHS Found…
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a comprehensive care and treatment plan for core needs.
Katie Horne
All Responded
2022-0253 11 Aug 2022
Princess Royal Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, hindering timely and effective care.
Locksley Burton
All Responded
2022-0236 29 Jul 2022
QHS GP Care Home Tower Bridge Care Home Kings College Hospital
Care Home Health related deaths Other related deaths
Concerns summary Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.
Ian Taylor
All Responded
2022-0173 8 Jun 2022
Metropolitan Police Service Independent Office for Police Conduct
Police related deaths
Concerns summary Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.
Mark Castley
All Responded
2021-0427 22 Dec 2021
HM Prison and Probation Service
Other related deaths Suicide (from 2015)
Concerns summary The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
Abiodun Oritogun
All Responded
2021-0248 13 Jul 2021
University Hospital Lewisham
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by capacity, not clinical need.
Ella Kissi-Debrah
All Responded
2021-0113 20 Apr 2021
Department for Environment British Thoracic Society National Institute for Health and Care … +11 more
Child Death (from 2015) Community health care and emergency services related deaths Other related deaths
Concerns summary National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.