North London

Coroner Area
Reports: 74 Earliest: Aug 2013 Latest: 6 Mar 2026

73% response rate (above 62% average).

Response Status
Responded 54 Historic 18 Pending 2
AI Classification
Action Taken 40%
Action Planned 30%
Noted 27%
Disputed 3%
Based on 30 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Other related deaths (10) Child Death (from 2015) (8) Suicide (from 2015) (8) Community health care and emergenc… (7)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: -62 reports · +15pp response rate
vs national average: -9 reports · +11pp response rate
74 results
Simon Delahunty
All Responded
2020-0077 24 Mar 2020
Department of Health and Social Care
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.
Joseph Charles
Partially Responded
2019-0277 6 Aug 2019
Department of Health and Social Care North Middlesex University Hopsital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, despite clear guidance for lower limb procedures.
Priscilla Tropp
All Responded
2019-0213 24 Jun 2019
Department for Transport Office of Rail and Road Govia Thameslink Railway
Other related deaths
Concerns summary The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Suleyman Yalcin
All Responded
2018-0368 20 Nov 2018
Metropolitan Police
Alcohol, drug and medication related deaths Road (Highways Safety) related deaths
Concerns summary Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Alba Pemberton
All Responded
2018-0288 10 Sep 2018
Department of Health and Social Care
Child Death (from 2015)
Concerns summary Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
Jonathan Zucker
All Responded
2017-0433 26 Jun 2017
Department of Health and Social Care Royal College of Psychiatrists
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Howard Jeffers
All Responded
2017-0115 15 May 2017
Drug Misuse and Novel Psychoactive Subs… Pharmaceutical Chemistry University of Hertfordshire
Product related deaths
Concerns summary The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.
Stephen Leven
All Responded
2017-0158 15 May 2017
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
George Dicker
Historic (No Identified Response)
2017-0083 13 Mar 2017
RSSB
Railway related deaths
Concerns summary There is no alarm or warning system to alert railway signallers when a person accesses the tracks via a gate at the end of a platform.
James Fox
All Responded
2017-0014 2 Feb 2017
Metropolitan Police Service
Police related deaths
Concerns summary Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Lauris Kodors
Historic (No Identified Response)
2016-0357 13 Sep 2016
RSSB
Railway related deaths
Concerns summary The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is in danger from an approaching train.
Arthur Adley
All Responded
2016-0358 13 Sep 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Benjamin Brown
Historic (No Identified Response)
2016-0326 5 Sep 2016
Edgware Community Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
Ezharul Islam
All Responded
2016-0214 6 Jun 2016
Transport for London
Other related deaths
Concerns summary There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and a bell.
Carole Lovett
Historic (No Identified Response)
2016-0174 6 May 2016
North Middlesex Hospital
Mental Health related deaths
Concerns summary Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration for alternative patient monitoring.
Kristian Jaworski
All Responded
2016-0125 4 Apr 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.
Parv Patel
All Responded
2015-0457 29 Sep 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.
Anthony Dwyer
All Responded
2015-0249 30 Jul 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.
Michael Bovell
Historic (No Identified Response)
2015-0248 29 Jun 2015
Rail Safety and Standards Board
Community health care and emergency services related deaths
Concerns summary The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a gap in preventing harm to trespassers on the line.
Arti Lakhani
All Responded
2015-0217 10 Jun 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.
Amanda Harris
Historic (No Identified Response)
2015-0216 10 Jun 2015
Mount Vernon Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.
Lewis Ghessen
Historic (No Identified Response)
2015-0213 9 Jun 2015
Rail Safety and Standards Board
Railway related deaths
Concerns summary The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from a train.
Paul Murray
All Responded
2015-0193 13 May 2015
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Hana Elhamid
All Responded
2015-0194 13 May 2015
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.
Ronald Gittens
All Responded
2015-0117 12 Mar 2015
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment Teams as a barrier to inpatient bed access.