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
108 results
Philip Dean
Partially Responded
2014-0172 15 Apr 2014
Clinical Commissioning Group for Wandsw… South Wet London and St George’s Mental…
Mental Health related deaths
Concerns summary (AI summary) Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
Action Taken (AI summary) South West London and St George's NHS Trust has revised serious incident procedures so that initial findings from concise investigations are reviewed after ten working days to consider escalating to a comprehensive investigation if necessary. They have commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing.
Desiree Falvo
All Responded
2014-0171 15 Apr 2014
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
Action Taken (AI summary) NHS England highlights existing training for A&E staff in emergency airway procedures and a review of Emergency Departments. They have agreed that major trauma units have consultants on site 24/7 and all A&Es will have senior training doctors on site 24/7.
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.
Refat Hussain
All Responded
2014-0061 12 Feb 2014
Harmoni HS
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Noted (AI summary) Care UK acknowledges the coroner's concerns regarding access to patient information and describes existing systems for receiving information from GPs, including post-event messages, Special Patient Notes, Summary Care Records, and Coordinate My Care in London. They emphasize that the onus is on the registered GP practice to enable access.
Daniel Maurice McMahon
Partially Responded
2013-0271 21 Nov 2013
Department of Health and Social Care LAS Legal Services Metropolitan Police +1 more
Railway related deaths
Concerns summary (AI summary) The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending the rule book to require trains to stop when a potentially unwell person is trespassing; and reviewing guidance on lung decompression needles for the ambulance service.
Disputed (AI summary) The London Ambulance Service reviewed the use of one-way valves on needle chest decompressions and concluded that their current approach of not using them is appropriate, citing expert opinions and consensus statements. The Department of Health is reviewing the advice in the 'Code of Practice Mental Health Act 1983', including the chapter on leave of absence under section 17 and references to care planning, using this case to assist that review.
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.