Inner South London
Coroner Area
Reports: 146
Earliest: Aug 2013
Latest: 7 Apr 2026
81% response rate (above 63% average).
Adrian Ashford
All Responded
2020-0054
7 Feb 2020
Queen Elizabeth Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make appropriate specialist referrals for a deteriorating patient.
Action Taken
(AI summary)
Lewisham and Greenwich NHS Trust has implemented a trust-wide electronic patient record system that enables weight to be consistently recorded and observed by all staff. The consultant involved in the case has conducted a case review and reflection to use in their annual appraisal, and a new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332
1 Nov 2019
Department for Transport
Metropolitan Police Service
British Vehicle Rental and Leasing Asso…
+6 more
Other related deaths
Concerns summary (AI summary)
The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted
(AI summary)
The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.
Derek Weaver
All Responded
2019-0345
15 Oct 2019
Department of Health and Social Care
Guys & St Thomas NHS Trust
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.
Noted
(AI summary)
The Department of Health acknowledges the concerns, notes that NHS England is responding separately, and highlights peer review activities of thoracic services in London and oversight to ensure timely access to thoracic surgery. The response also references the legal duty of candour for NHS trusts during investigations. The Trust has implemented a new triage process managed by Site Nurse Practitioners, enabling prioritization of patients needing urgent admission within 48 hours. They are also looking at an electronic referral system and increasing the number of beds for Thoracic Surgery patients by Q1 2020. NHS England is reviewing capacity for thoracic surgery, including critical care beds, in light of new lung cancer pilots and concerns raised. They will keep pathways under review to ensure timely access to high-quality services.
Alex Malcolm
Partially Responded
2019-0344
15 Oct 2019
Department of Health and Social Care
HM Prison & Probation Service
MOJ
Child Death (from 2015)
Concerns summary (AI summary)
Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Action Taken
(AI summary)
HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues.
Owen Carey
All Responded
2019-0335
30 Sep 2019
British Society for Allergy and Clinica…
Byron Hamburgers
Department of Environment, Food and Rur…
+3 more
Other related deaths
Product related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Byron has rectified the lack of records kept of on-job training immediately and each employee will now have records kept, and are investing in a market leading training system called "Flow" which is launched in the business from November where every employee will have their own personal training modules and records. BSACI will write to the chair of the FSA to advocate for funding for the UK Fatal Anaphylaxis Registry (UKFAR), which they are exploring closer working with to ensure its sustainability. National Trading Standards states that food safety and allergen regulation is outside their remit, which focuses on regional or national issues like complex consumer fraud. They note the Food Standards Agency is responsible for allergen legislation and policy. The FSA plans to develop an online reporting system and improve data sharing for allergic reactions, including those not resulting in death, to enable timely identification of trends and action by local authorities. DHSC will work to increase information prevalence on anaphylactic deaths and will support the FSA's reporting platform.
Francis Hodge
All Responded
2019-0338
24 Sep 2019
University Hospital Lewisham
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients, and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective.
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 (AI 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.
Action Taken
(AI summary)
KMPT has reviewed its Transfer and Discharge of Care policy, developed a shared care protocol with local universities, created a fast-track referral route from universities to the Community Mental Health Team, piloted a direct referral form from the University Health Centre, strengthened the Consent to Share Information process, and incorporated the South London and Maudsley's Transient People policy.
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 (AI 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.
Action Taken
(AI summary)
The Trust's C-diff Action Group reviewed the Trust's C-diff investigation process and revised it to include a stage to check whether the mandatory infection control data forms need to be sent to another ward in addition to the ward where the patient is currently located.
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 (AI 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.
Action Taken
(AI summary)
The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust and NHS Professionals to address referral delays and ensure prompt referrals in the future. They have also referred concerns about the HCA to the Care Quality Commission. NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to manage complaints and investigations. They also use a Complaints and Incidents Management System (CIMS) feedback form to address concerns raised by Client Trusts.
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 (AI 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.
Action Taken
(AI summary)
South Western Railway has updated its on-board procedure for medical emergencies, including the Guard, Driver, Control Centre and Signallers, to optimize the time taken to determine the best station for ambulance services to assist. They have also updated the Driver's section of the Booklet to advise passengers about the limitations of the Pass-Com system. The British Heart Foundation has invested over £2m in its 'Nation of Lifesavers' programme, training over 5.5m people in CPR, and is funding CPR kits in over 85% of UK secondary schools. They are also investing over £4.5m in developing 'The Circuit,' a national defibrillator network connected to ambulance services.
Feni Lee
Partially Responded
2019-0224
28 Jun 2019
Erith Health Centre, 50 Pier Rd, Erith,…
Bexley Medical Group
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The practice has started implementing a plan to carry out medication reviews in all patients who have not had a review for over 12 months. The practice has discussed the report with Riverside Medical Practice and they have agreed to send letters via email and in person.
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 (AI 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.
Noted
(AI summary)
London Ambulance Service outlines the operational policy for dispatch of resources in any category of call, and provides details of the systems in place to identify caller location. It also notes future developments that will further improve efficiency.
Bernard O’Flynn
Historic (No Identified Response)
2019-0488
8 May 2019
Oxleas NHS Trust
State Custody related deaths
Concerns summary (AI 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.
Edward Hearn
All Responded
2019-0479
8 May 2019
Amgen Limited
Kings College Hospital
Medicines and Healthcare products Regul…
+3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Disputed
(AI summary)
The case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up, and work is ongoing to highlight the importance of reviewing test results on inpatients daily. A Safety Net is being prepared, and KCH and the PRUH standard lab comments to GP‟s for outpatient Biochemistry will be aligned. Amgen believes that cardiac monitoring guidance is already definitively outlined in the prescribing information for Kyprolis, and that no further revisions to the SmPC are required. However, they will continue to conduct ongoing pharmacovigilance of Kyprolis and evaluate their SmPC guidance on cardiac monitoring. The MHRA considered whether the statutory information currently provided by the marketing authorisation holder for prescribers and patients on the safe use of carfilzomib is adequate. The statutory product information for cyclophosphamide and dexamethasone was also considered.
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 (AI 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 (AI 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.
Noted
(AI summary)
The Department for Transport states it is updating the Traffic Signs Regulations and General Directions (TSRGD), including Chapter 5 on pedestrian crossings, with updated advice on the design of pedestrian facilities, therefore no further action is considered necessary.
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 (AI summary)
The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC process's inability to protect chaotic, non-engaging individuals, alongside concerns about GPs' knowledge of disclosing confidential information.
Noted
(AI summary)
The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation.
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 (AI 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 (AI summary)
Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.
Action Taken
(AI summary)
Lewisham Council arranged for the cutting back of tree foliage and remarked the northbound and southbound "SLOW" markings. The council proposed to reconstruct the speed cushions near pedestrian refuge crossing points by the end of April 2019.
REDACTED
Partially Responded
2022-0036
5 Nov 2018
Broadgate General Practice
General Medical Council
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
The GMC has opened an investigation in relation to Dr. A and will require an expert report to comment on the care provided. The outcome of the investigation may result in the doctor being given advice, issued a warning, agreeing to undertakings, or referral to the Medical Practitioners Tribunal Service.
Thomas McAuley
Partially Responded
2018-0309
29 Oct 2018
Serco Ltd
Metropolitan Police Service
Oxlea NHS Trust
+1 more
State Custody related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The MPS is working to implement a communication network (N3) and hardware into all custody suites, to provide healthcare professionals with access to NHS Summary Care Records and is required for an EMRS, anticipated within a year. A new PER will be introduced in April 2019 and the MPS will introduce the EMRS platform within one year.
Nigel Handscomb
Historic (No Identified Response)
2018-0278
1 Aug 2018
Eden Park Surgery
Community health care and emergency services related deaths
Concerns summary (AI 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
The Chief Coroner
+1 more
Child Death (from 2015)
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Lambeth Council has offered safeguarding training to the South Lambeth Islamic Centre, scheduled for September 19th, and shared a model safeguarding policy for schools; the Council's Food, Health and Safety Manager will follow up on the actions via a visit.
Edward Joyce
Partially Responded
2018-0142
9 May 2018
Chelsea & Westminster Hospital
Medical Protection Society
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Trust states the evidence indicates a temperature spike was not mentioned during the phone call, and the national information leaflet contains accepted advice and correct symptoms for burns injuries. The Paediatric Burns Network has been alerted, and the burns unit can be contacted by telephone 24 hours every day.
William Dickens
Partially Responded
2018-0137
8 May 2018
South London & Maudsley NHS Trust
The Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.
Action Planned
(AI summary)
The Director of Nursing will issue a safety alert, and ward managers will hold learning conversations with nurses regarding observation practices. The Therapeutic Engagement and Observation Policy will be reviewed, and new nurses and nursing trainees will receive a "Learning the Lessons" presentation. Six-monthly audits will be commissioned to establish compliance, and a timeline is being developed for transforming observations into an e-observation framework.