Inner West London
Coroner Area
Reports: 107
Earliest: Nov 2013
Latest: 10 Mar 2026
60% response rate (below 62% average).
Debapriya Ghosh and David Ward
All Responded
2025-0634
17 Dec 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Action taken summary
The Department for Health and Social Care acknowledges A&E staffing and demand concerns, highlighting actions already implemented by St George’s Trust. DHSC's own response outlines a 2025/26 Urgent an
Tony Duncan
All Responded
2025-0516
15 Oct 2025
South London and Maudsley NHS Foundatio…
Mental Health related deaths
Suicide (from 2015)
Concerns summary
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Action taken summary
The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low In
Gareth Jackson
All Responded
2025-0417
8 Aug 2025
South West London and St Georges Mental…
Suicide (from 2015)
Concerns summary
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national bed crisis also delayed transfer.
Raihana Oluwadamilola Awolaja
All Responded
2025-0212
2 May 2025
Children’s Trust
Care Home Health related deaths
Child Death (from 2015)
Concerns summary
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Brandon Johnson
All Responded
2024-0523
1 Oct 2024
HMP Wandsworth
State Custody related deaths
Concerns summary
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
Judith Obholzer
All Responded
2024-0377
12 Jul 2024
NHS England
South West London and St George’s Menta…
Department of Health and Social Care
Suicide (from 2015)
Concerns summary
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for patients.
Juan Martin
All Responded
2024-0315
11 Jun 2024
Department of Health and Social Care
South West London and St George’s Menta…
NHS South West London Integrated Care B…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.
James Furlong, Joseph Ritchie-Bennett and David Wails
All Responded
2024-0276
20 May 2024
Berkshire Healthcare NHS Foundation Tru…
Ministry for Justice
Home Office
+4 more
Other related deaths
Concerns summary
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed to the Deaths".
Adrian James
All Responded
2024-0128
7 Mar 2024
NHS England
Central and North West London NHS Found…
Mental Health related deaths
Suicide (from 2015)
Concerns summary
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Lee Hughes
All Responded
2024-0120
4 Mar 2024
Oxleas NHS Trust
NHS England
Alcohol, drug and medication related deaths
Concerns summary
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities for escalation and appropriate care were missed.
Roberto Bottello
All Responded
2024-0087
16 Feb 2024
Metropolitan Police Service
NHS England
Central and North West London NHS Found…
Mental Health related deaths
Concerns summary
Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
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
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.
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
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.
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
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.
Oleg Khala
All Responded
2023-0231
6 Jul 2023
West London NHS Trust
Suicide (from 2015)
Concerns 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.
Arezou Tirgari
All Responded
2023-0226
3 Jul 2023
Landsec
Suicide (from 2015)
Concerns 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.
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
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.
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
The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
Fishmongers’ Hall Inquests
All Responded
2021-0362
3 Nov 2021
West Midlands Police
College of Policing
Office for Students
+7 more
Other related deaths
Police related deaths
State Custody related deaths
Concerns summary
The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific coroner's concerns regarding systemic failures or safety issues for future prevention.
Daniel Mervis
All Responded
2021-0027
3 Feb 2021
Oxford University
St John’s College
Alcohol, drug and medication related deaths
Concerns 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.
Tyereece Johnson
All Responded
2019-0166
23 May 2019
Metropolitan Police
Child Death (from 2015)
Emergency services related deaths (2019 onwards)
Police related deaths
Concerns summary
The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Alfonso Sinclair
All Responded
2019-0141
29 Apr 2019
Transport for London
Alcohol, drug and medication related deaths
Railway related deaths
Concerns summary
A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of system to alert odd behaviour or alarms at platform end barriers.
Georgia Nelson
All Responded
2019-0140
29 Apr 2019
Central and North West London NHS Trust
Royal Borough of Kensington and Chelsea
Mental Health related deaths
Railway related deaths
Concerns summary
Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide following a mental health relapse.
Marian Hoskins
All Responded
2019-0005
9 Jan 2019
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
All Responded
2018-0304
19 Dec 2018
Speaker’s Counsel, for the attention of…
British Vehicle Rental and Leasing Asso…
Department for Transport
+5 more
Other related deaths
Concerns summary
A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.