Inner South London

Coroner Area
Reports: 146 Earliest: Aug 2013 Latest: 7 Apr 2026

81% response rate (above 63% average).

146 results
Kathryn Bull
Historic (No Identified Response)
2016-0188 27 Apr 2016
British Obesity and Metabolic Surgery S…
Other related deaths
Concerns summary (AI summary) Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not well known.
Edward Paddon-Bramley
Partially Responded
2016-0099 6 Mar 2016
Department of Health and Social Care National Screening Committee N.I.C.E +1 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Action Planned (AI summary) The UK NSC commissioned an update review into antenatal screening for GBS in December 2015 and expects to hold a public consultation in the autumn for three months, after which the UK NSC will review its recommendation. Research is also underway to evaluate the value of using rapid tests in labour to detect GBS in women with risk factors. The Department of Health notes concerns about differing guidelines for prolonged ruptured membranes (PROM) and GBS screening. They highlight that NICE guidelines represent best practice and that the RCOG provides updated guidance. They are monitoring developments on GBS vaccines, have completed a national surveillance study on GBS, have carried out an audit of current practice in preventing early onset neonatal Group B Streptococcal disease, and have approved funding for a study on accuracy of a rapid intrapartum test.
Christ Morrison
Partially Responded
2016-0084 2 Mar 2016
Epsom and St Helier, University Hospita… Queen Mary’s Hospital for Children
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.
Action Taken (AI summary) Epsom and St Helier University Hospitals NHS Trust reviewed and updated the Trust's 2015 Tracheostomy Policy to give clearer sign posting to national guidelines. The updated policy has been submitted to The Royal College of Child Health and The Paediatric Intensive Care Society for review and the Trust continued with its annual training programme for all staff involved in tracheostomy care.
Jakovas Fofonovas
All Responded
2016-0077 26 Feb 2016
Network Rail
Railway related deaths
Concerns summary (AI summary) Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of the inquest.
Action Taken (AI summary) Network Rail demolished and replaced the footbridge at Bostall Manor Way with a new, safer design, including industry standard height railings (1250mm) and acoustic fencing with anti-climb extensions. Old building materials have been removed from the site.
Matthew Wood
Partially Responded
2016-0001 4 Jan 2016
Civil Aviation Authority Department for Transport London Heliport
Other related deaths
Concerns summary (AI summary) There is no policy of reporting anything encroaching flight paths to the Heliport; the London Heliport should be a safeguarded aerodrome. The local planning authority did not respond to concerns.
Action Planned (AI summary) The London Heliport is pursuing officially safeguarded status and working with the CAA/EASA, local government, and NATS. They are awaiting a response from the DfT regarding the case for official safeguarding. The CAA is reviewing the safety of onshore helicopter operations in the UK, will work with the helicopter community, and is planning a seminar on safety culture for the commercial helicopter industry. They will also actively engage with the DfT and DCLG regarding building obstacle impact assessments.
Peter Barnes
Partially Responded
2016-0001-wp25050 4 Jan 2016
Civil Aviation Authority Department for Transport London Heliport
Other related deaths
Concerns summary (AI summary) Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite clear risks to flight paths.
Action Planned (AI summary) • The London Heliport has continued its correspondence with both CAA and DfT in order to provide information to progress consideration of official safeguarding of the London Heliport and assist them with implementation of AAIB report recommendation 2014-30. • The DfT will treat the email as a formal application for official safeguarding whilst asking for further documentary evidence to support the application. • The DfT will consult the CAA and the Department for Communities and Local Government to determine what other measures, if any, are available to ensure that local planning authorities give due regard to safeguarding concerns the London Heliport when granting planning permission. • The Flight Operations team is conducting a review of the safety of onshore helicopter operations in the UK this year. • The review will include a post implementation review of the Standardised European Rules of the Air (SERA). • The CAA will work with the helicopter community to consider whether there are any recommendations or industry best practice that could be incorporated into regulation or regulatory guidance material.
Imran Douglas
Partially Responded
2015-0446 29 Dec 2015
General Medical Council London Borough of Tower Hamlets National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties from YOT/YJB to PMU at age 18. Also, there appeared to be a disconnection between Looked After Child pathway planning and Transition Planning.
Action Planned (AI summary) • Leeds City Council has been working to design a scheme which provides safe pedestrian assisted facilities across the Ring Road at this location and the neighbouring Coal Road junction. • Design considerations have been concluded and a final layout has been confirmed, which will be compatible with proposed future improvements planned at the Coal Road/ Ring Road junction and also longer term aspirations along this strategic corridor. • A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction.
Ololade Olaobaju
Historic (No Identified Response)
10 Dec 2015
ENT UK Royal College Anaesthetists
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent clinical judgments and limited practitioner experience.
Rosina Drury
Historic (No Identified Response)
2015-0397 2 Oct 2015
Kings College Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Lee Bates
Partially Responded
2015-0381 17 Sep 2015
Guys and St Thomas NHS Trust Cambian Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.
Action Taken (AI summary) Cambian Group has met with St Thomas' and agreed a protocol to reduce the possibility of inadequate communication or care in the future.
Darren Browne
Historic (No Identified Response)
1 Sep 2015
Police of the Metropolis
Other related deaths
Concerns summary (AI summary) A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs and risks against restrictions.
Wiktoria Was
All Responded
2015-0271 13 Jul 2015
Metropolitan Police
Police related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.
Action Taken (AI summary) The Metropolitan Police Service has rolled out an RT Operators Course since 2011 to selected elements of the uniformed workforce and since July 2014 to all new recruits. They are also planning to implement enhanced driver training, pending release of funds, and are working to ensure officers serving prior to the course introduction may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.
Michael George
All Responded
2015-0264 9 Jul 2015
South London and Maudsley Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill patients, and there was a lack of domiciliary visits from consultant physicians to mental health wards.
Action Planned (AI summary) South London and Maudsley NHS Trust outlines planned improvements to policies, audits, and risk management related to physical health monitoring for patients on anti-psychotics, including actions related to diabetes screening and refusal of tests. They are considering adding the Glasgow Anti-psychotic Side-effects Scale (GASS) to their electronic patient record and have set up a working group as part of the London Strategic Clinical Network.
Matthew Hoare
All Responded
2015-0203 27 May 2015
National Rail
Railway related deaths
Concerns summary (AI summary) Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
Action Taken (AI summary) Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre.
Laurence Boyens
Partially Responded
2015-0156 22 Apr 2015
General Medical Council General Midwifery Council Healthcare UK +2 more
State Custody related deaths
Concerns summary (AI summary) Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Noted (AI summary) Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and will pass the case for a decision by January 8, 2015. The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write to the referring party with their decision.
Archie Hexall
All Responded
2015-0081 5 Mar 2015
Lewisham and Greenwich NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.
Action Taken (AI summary) Lewisham Greenwich NHS Trust has implemented actions, including a 'learning from incidents' policy requiring staff to document and handover clear information and a review of handover documentation. They have also used initiatives such as Goldfish Bowl and Whose Shoes? to improve communication between staff and service users.
Maria Nekrasova
All Responded
2015-0141 20 Feb 2015
Department for Transport London Borough of Lambeth City of Westminster +1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary) The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where oncoming headlights blinded drivers to pedestrians in the carriageway.
Action Planned (AI summary) TfL will conduct a detailed investigation of lighting levels on Westminster Bridge by August 2015 and consider appropriate alterations, also public consultation in summer 2015 on the road layout across the bridge as part of TfL's 'Better Junctions' works programme.
Max Carlton-Smith
All Responded
2015-0007 14 Jan 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked sufficient powers to intervene effectively in squatted commercial premises.
Noted (AI summary) The Home Office believes the police have sufficient powers under existing legislation (Criminal Justice and Public Order Act 1994) to prevent and stop illegal raves. The use of these powers is an operational matter for the police.
Moses McDonald
Partially Responded
2014-0524 2 Dec 2014
Russell-Cooke solicitors South London and Maudsley NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Action Taken (AI summary) The Trust updated its physical healthcare policy to outline the responsibility of clinical staff to address patient's physical health needs and made it mandatory that all patients prescribed anti-psychotic medication should have a physical health check. The Trust will conduct a full review of the Clozapine clinics across the 4 boroughs within the next 6 months.
Sandra Higham
All Responded
2014-0479 3 Nov 2014
Department of Health and Social Care Public Health England The Heart Rhythm Society of the United …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Noted (AI summary) BHRS will include an article on avoidance and recognition of atrio-oespohageal fistula in its winter newsletter and remind members to ensure this complication is recorded in the national cardiac rhythm management database. BHRS will work with the AF Association and A-A to re-design the information relating to complications of AF ablation to include information on recognition of symptoms and a leaflet will be developed by the end of March 2015. Public Health England states that the case is not something they can directly assist with, but understand that the Department of Health will contact appropriate bodies. The Department of Health contacted the BCS who are considering circulating a letter to relevant surgeons. A copy of the coroner's letter and the response from the Department of Health will be sent to the BCS and the RCS.
Christopher Ajayi
All Responded
2014-0558-wp26761 31 Oct 2014
South London and Maudsley trust
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.
1 response from South London and Maudsley NHS Trust
Philip Allen
All Responded
2014-0466 27 Oct 2014
Eltham Palace Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Action Taken (AI summary) The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly requested an N3 line for direct access to patient records and have purchased laptops for some record access.
Samuel Duckworth
All Responded
2014-0456 20 Oct 2014
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.
Noted (AI summary) The Home Office acknowledges concerns about the supply of prescription-only medicines online, noting ongoing work with law enforcement and internet providers to close illegal websites. They highlight international collaboration and monitoring efforts but describe no new actions.
Yaser Saleh
Historic (No Identified Response)
2014-0453 17 Oct 2014
Department of Health and Social Care EMIS Health Iveagh Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
Arsema Dawit
All Responded
2014-0442 13 Oct 2014
Metropolitan Police Service
Police related deaths
Concerns summary (AI summary) Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
Action Taken (AI summary) The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.