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
107 results
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… NHS England Cygnet Health Care
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.
Refat Hussain
All Responded
2014-0061 12 Feb 2014
Harmoni HS
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Daniel Maurice McMahon
Partially Responded
2013-0271 21 Nov 2013
Metropolitan Police LAS Legal Services RSSB +1 more
Railway related deaths
Concerns summary Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, and an outdated railway rule book concerning stopping trains for unwell individuals on tracks.
Action taken summary The London Ambulance Service disputes the concern regarding the use of needle chest decompressions without a valve, stating that a review by their Medical Director concluded their current practice is
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.
Zsolt Kirjak
Response Pending
2022-0197
Central and North West London NHS Found… Imperial College health Care NHS Trust … Portland Practice
Mental Health related deaths Suicide (from 2015)
Concerns 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.