Inner West London

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

62% response rate (below 63% average).

Response Status
Responded 67 No Response 6 Historic 33 Pending 1
AI Classification
Action Taken 45%
Action Planned 35%
Noted 18%
Disputed 2%
Based on 120 classified responses
Top Categories
Hospital Death (Clinical Procedure… (42) Suicide (from 2015) (22) Mental Health related deaths (19) Other related deaths (14) Child Death (from 2015) (13)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: -30 reports · +5pp response rate
vs national average: +24 reports · -1pp response rate
Clear 33 results
Karen O’Brien
Historic (No Identified Response)
15 Jul 2015
First Response Team, South Essex Partne… NICE
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Tommy Faisali
Historic (No Identified Response)
6 Jul 2015
Central and North West London NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
Samia Shara
Historic (No Identified Response)
2014-0548 19 Dec 2014
NHS England North West Collaborative Clinical Commi…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
Keiran Toman
Historic (No Identified Response)
2014-0225 12 May 2014
Hafod Community Mental Health Team NHS England Windsor and Maidenhead Community Mental… +1 more
Mental Health related deaths
Concerns summary (AI summary) Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.
John Fox
Historic (No Identified Response)
2014-0098 5 Mar 2014
St George’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
John Davies
Historic (No Identified Response)
2014-0063 13 Feb 2014
General Medical Council Medical Protection Society Royal College of Physicians
Other related deaths
Concerns summary (AI summary) GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.
Lisa Inkin
Historic (No Identified Response)
2014-0062 13 Feb 2014
Cygnet Health Care Kent and Medway Mental Health Directora… NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.
Joanne Manning
Historic (No Identified Response)
2013-0289 1 Nov 2013
The Practice The Practice Practice
Community health care and emergency services related deaths
Concerns summary (AI summary) A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.