Inner West London

Coroner Area
Reports: 108 Earliest: Nov 2013 Latest: 25 Mar 2026

62% response rate (below 63% average).

108 results
Samuel Parkin
All Responded
2025-0361 18 Jan 2024
NHS England St George’s University Hospitals NHS Fo…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Action Planned (AI summary) NHS England will issue national guidance around the limitations of ultrasound to diagnose malrotation and the provision of second opinions, highlighting the importance of communication between teams and multi-disciplinary discussion. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. St George's has summarised learning from the case and is presenting at governance meetings; met with Epsom & St Helier; leading a malrotation session; and formalised written referrals to paediatric gastroenterology. They also hold a monthly Paediatric Gastroenterology Radiology meeting to improve communication.
Chloe Macdermott
Partially Responded
2023-0534 19 Dec 2023
Amazon Border Force British Transport Police +6 more
Suicide (from 2015)
Concerns summary (AI summary) Online forums encourage suicide by providing methods without age restrictions or help signposting, and harmful content is not effectively removed. Lethal products are also easily purchased via international online retailers and delivered to the UK without effective border controls.
Action Planned (AI summary) Amazon has globally restricted the sale of high concentration sodium nitrite to Amazon Business customers since October 2022 and prohibits the sale of poisons as defined under Schedule 1A of the UK Poisons Act 1972. The NPCC Suicide Prevention Steering Group has disseminated briefing materials to all NPCC force and regional suicide prevention leads regarding the emerging trend of Sodium Nitrate and Nitrite use in suicides. They have also supported the National Crime Agency's criminal investigation into the supply of Sodium Nitrite. Ofcom is implementing the Online Safety Act 2023, developing codes of practice to address illegal content and protect children, and will take enforcement action against non-compliant services, including financial penalties and business disruption measures. Google Search prevents predictions for queries relating to methods of suicide and provides prominent signposting to authoritative information and support when users search for suicide-related terms, and delists content that directly facilitates activities that could cause immediate harm. DSIT outlines how the Online Safety Act will force companies to take more accountability for the safety of their users, including those who use VPNs to bypass protections, and details Ofcom's enforcement powers for non-compliant services. DHSC leads a cross-government group to tackle emerging methods of suicide, including sodium nitrite, reducing public access, and working with retailers to ensure labeling compliance for products like curing salt.
David Hemmings
Historic (No Identified Response)
2023-0529 18 Dec 2023
Choice Support
Care Home Health related deaths
Concerns summary (AI summary) Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.
Boycie Chatterton
Historic (No Identified Response)
2023-0483 27 Nov 2023
Department of Health and Social Care NHS England
Child Death (from 2015)
Concerns summary (AI summary) The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.
Kai Takagi
Partially Responded
2023-0502 27 Oct 2023
Chelsea and Westminster Hospital NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
Noted (AI summary) NHS England highlights existing national guidance and standards for following up on test results after discharge and refers to their urgent and emergency care recovery plan, noting the responsibility of Trusts to implement procedures and follow national guidance.
Federica Cavenati
Historic (No Identified Response)
2023-0410 25 Oct 2023
Medicines and Healthcare products Regul…
Suicide (from 2015)
Concerns summary (AI summary) There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for vulnerable individuals.
Benjamin McQueen
All Responded
2023-0285 28 Jul 2023
Ministry of Defence
Accident at Work and Health and Safety related deaths Other related deaths Service Personnel related deaths
Concerns summary (AI summary) Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.
Action Taken (AI summary) The Ministry of Defence has reviewed and aligned figures in the Divers Policy (JSP286) and the maintenance Policy (BR2807), stipulating the minimum abort pressure as 50 Bar, and updated the figures prescribed for tolerances to the minimum pressure to start a dive.
Peter Harris
All Responded
2023-0260 20 Jul 2023
Barking, Havering and Redbridge Univers…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.
Action Planned (AI summary) Barking, Havering and Redbridge University Hospitals NHS Trust will alert referrers to all imaging with expected, unexpected, or newly detected cancer, and critical non-cancer findings, with actions tracked in a version-controlled action plan. They will develop and implement a Standard Operating Procedure (SOP) for radiological findings of cancer, as well as a SOP for lung nodules identified as an incidental finding.
Oleg Khala
All Responded
2023-0231 6 Jul 2023
West London NHS Trust
Suicide (from 2015)
Concerns summary (AI summary) A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Action Planned (AI summary) West London NHS Trust is implementing NICE guidance (NG225), undertaking an audit of CATT processes by December 2023, and providing additional training for staff regarding ASD. They are also in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention.
Arezou Tirgari
All Responded
2023-0226 3 Jul 2023
Landsec
Suicide (from 2015)
Concerns summary (AI summary) Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing risk of further fatalities.
Action Taken (AI summary) Landsec has implemented measures including a two-metre exclusion zone, warning signs, planters, and security officers to prevent access to the perimeter wall at One New Change's roof terrace.
Daniel Lyle
Historic (No Identified Response)
2023-0170 23 May 2023
College of Policing Metropolitan Police Service
Mental Health related deaths
Concerns summary (AI summary) A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The officer's training was described as a "patchwork" over many years.
Elsie Leaver
Historic (No Identified Response)
2023-0139 26 Apr 2023
St Georges University Hospital NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) The report concerns a delay in a doctor returning a call to the family regarding concerns about the deceased's active suicidality.
Nicola Norman
Historic (No Identified Response)
2023-0097Deceased 14 Mar 2023
Central and North West London NHS Found…
Suicide (from 2015)
Concerns summary (AI summary) The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Annabel Findlay
All Responded
2023-0080Deceased 1 Mar 2023
Priory Hospital
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.
Action Taken (AI summary) The Priory Group has circulated reminders to medical colleagues to ensure outpatient follow-up appointments are booked prior to patient discharge. They have also reminded staff to make telephone contact with patients 48 hours after discharge and are auditing this process monthly.
Zsolt Kirjak
Response Pending
2022-0197
Portland Practice, Central and North We…
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors and previous self-harm attempts. His wife was not given opportunity to contribute to assessments.
Raymond Griffiths
All Responded
2022-0135 9 May 2022
NHS England St George’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
Disputed (AI summary) The Trust details actions taken to improve patient safety in cardiac surgery, including addressing staffing, governance, and collaborative working, and states the transition from restrictions to unrestricted working has been managed safely. Restrictions in cardiac surgery, removal of trainees and the fall in patient referrals did not create an increased risk of death to patients. NHS England provides a detailed response regarding cardiac services at St George's, defending the Independent Mortality Review and its findings, and asserting that it contributed to improvements in patient safety; it expresses concern that the PFD could hinder service restoration and public confidence.
Saima Usman
Historic (No Identified Response)
2022-0108 8 Apr 2022
London Borough of Wandsworth
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.
Manhareen Kaur
Historic (No Identified Response)
2022-0107 8 Apr 2022
London North West University Healthcare…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.
Fishmongers’ Hall Inquests
All Responded
2021-0362 3 Nov 2021
College of Policing Department for Education Home Office +7 more
Other related deaths Police related deaths State Custody related deaths
Concerns summary (AI summary) This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted (AI summary) CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.
Alice Pettersson
Historic (No Identified Response)
2021-0267 10 Aug 2021
Department of Health and Social Care
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.
Nicholas Winterton
Partially Responded
2021-0204 31 Mar 2021
College of Clinical Perfusion Scientists National Institute for Cardiovascular O… Public Health England +1 more
Hospital Death (Clinical Procedures and medical management) related deaths Product related deaths
Concerns summary (AI summary) The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Action Planned (AI summary) PHE will update risk estimates for Mycobacterium chimaera infection and publish them by September 2021, cascading the information to healthcare professionals through clinical networks; they will forward the request to update NHS guidance to NHS England.
Valeria Biggs
Historic (No Identified Response)
2021-0034 11 Feb 2021
Acute Mental Health Services, West Lond…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.
Daniel Mervis
All Responded
2021-0027 3 Feb 2021
St John’s College, Oxford University
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from seeking help.
Action Planned (AI summary) St John's College will adopt a template policy for drug misuse, rewrite the student handbook for clarity, and include information in Fresher's week. They will also run a Welfare week to raise awareness of drugs, addiction, and available support.
Rebecca Hursey
Historic (No Identified Response)
2020-0058 9 Mar 2020
NHS East Leicestershire and Rutland CGC NHS England Springfield Hospital
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.
John Long
Historic (No Identified Response)
2020-0011 14 Jan 2020
Chief Coroner of England & Wales Nursing and Midwifery Council St Georges University Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.