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 23%
Action Planned 53%
Noted 17%
Disputed 7%
Based on 30 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
Owen Carey
All Responded
2019-0335 30 Sep 2019
British Society for Allergy and Clinica… Byron Hamburgers Department of Environment +4 more
Other related deaths Product related deaths
Concerns summary The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false reassurance for customers.
Daniel Williams
All Responded
2019-0309 24 Sep 2019
St Thomas NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Rebecca Marshall
All Responded
2019-0313 24 Sep 2019
Kent and Medway NHS and Social Care Tru…
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental health care.
Francis Hodge
All Responded
2019-0338 24 Sep 2019
University Hospital Lewisham
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the absence of a patient information leaflet.
Alex Blake
All Responded
2019-0259 29 Jul 2019
NHS Professionals Ltd Nursing and Midwifery Council
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Annabel Newport
Partially Responded
2019-0240 17 Jul 2019
South Western Railways British Heart Foundation Office of Rail and Road
Other related deaths
Concerns summary Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system that allows drivers to prematurely terminate communication were significant safety concerns.
Feni Lee
All Responded
2019-0224 28 Jun 2019
Bexley Medical Group
Community health care and emergency services related deaths
Concerns summary An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.
Robert Cobbina
Partially Responded
2019-0210 25 Jun 2019
999 Liaison Committee Department for Culture, Media and Sport London Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location signage for a person in the river, causing significant delays in emergency response.
Edward Hearn
All Responded
2019-0479 8 May 2019
Medicines and Healthcare products Regul… Amgen Limited Kings College Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.
Bernard O’Flynn
Historic (No Identified Response)
2019-0488 8 May 2019
Oxleas NHS Trust
State Custody related deaths
Concerns summary Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases requiring immediate hospital transfer.
Royston Kemp
Historic (No Identified Response)
2019-0148 2 May 2019
Nursing and Midwifery Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.
Julia Peto
All Responded
2019-0119 4 Apr 2019
Department for Transport
Road (Highways Safety) related deaths
Concerns summary Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.
Donna Williamson
Partially Responded
2019-0111 27 Mar 2019
Department of Health and Social Care Home Office Local Government Association +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Systemic failures included lack of inter-agency responsibility for tenant safety, inadequate MARAC protection for vulnerable individuals, and insufficient GP awareness regarding disclosing confidential information for at-risk victims.
Gabriele Kreichgauer
Historic (No Identified Response)
2019-0082 22 Feb 2019
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Paul Fairey
All Responded
2018-0399 21 Dec 2018
London Borough of Lewisham
Road (Highways Safety) related deaths
Concerns summary Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.
REDACTED
Partially Responded
2022-0036 5 Nov 2018
General Medical Council Broadgate General Practice
Community health care and emergency services related deaths Suicide (from 2015)
Concerns summary A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric referral.
Thomas McAuley
Partially Responded
2018-0309 29 Oct 2018
Metropolitan Police Service Oxlea NHS Trust Thameside Prison
State Custody related deaths
Concerns summary Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently reviewed by prison medical staff.
Nigel Handscomb
Historic (No Identified Response)
2018-0278 1 Aug 2018
Eden Park Surgery
Community health care and emergency services related deaths
Concerns summary Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
Yunis Hadi
All Responded
2018-0209 30 Jun 2018
London Borough of Lambeth South London Islamic Centre
Child Death (from 2015) Other related deaths
Concerns summary A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.
Edward Joyce
All Responded
2018-0142 9 May 2018
Chelsea & Westminster Hospital
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.
William Dickens
All Responded
2018-0137 8 May 2018
South London & Maudsley NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.
Katy Roberts
All Responded
2018-0136 27 Apr 2018
South London & Maudsley NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients and families.
Rastislav Petrisko
Historic (No Identified Response)
2018-0067 6 Mar 2018
Oxleas Mental Health Trust
Mental Health related deaths
Concerns summary Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.
John Sloan
Unknown
12 Feb 2018
Mental Health related deaths
Concerns summary Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to provide supportive measures.
Michael Vukovic
All Responded
2018-0031 29 Jan 2018
Oxleas NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.