Inner West London

Coroner Area
Reports: 107 Earliest: Nov 2013 Latest: 10 Mar 2026

60% response rate (below 62% average).

Response Status
Responded 64 No Response 6 Historic 32 Pending 2
AI Classification
Action Taken 58%
Action Planned 25%
Noted 12%
Disputed 4%
Based on 24 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) (12)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: -29 reports · +2pp response rate
vs national average: +24 reports · -2pp response rate
Clear 32 results
Leslie Murray
Historic (No Identified Response)
2016-0016 21 Jan 2016
St George’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Samia Shara
Historic (No Identified Response)
2014-0548 19 Dec 2014
North West Collaborative Clinical Commi… NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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
Windsor and Maidenhead Community Mental… NHS England Hafod Community Mental Health Team +1 more
Mental Health related deaths
Concerns 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 Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Lisa Inkin
Historic (No Identified Response)
2014-0062 13 Feb 2014
Kent and Medway Mental Health Directora… Cygnet Health Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
John Davies
Historic (No Identified Response)
2014-0063 13 Feb 2014
General Medical Council Royal College of Physicians Medical Protection Society
Other related deaths
Concerns 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.
Joanne Manning
Historic (No Identified Response)
2013-0289 1 Nov 2013
Practice
Community health care and emergency services related deaths
Concerns 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.