North London

Coroner Area
Reports: 75 Earliest: Aug 2013 Latest: 6 Mar 2026

75% response rate (above 63% average).

75 results
Ronald Gittens
Partially Responded
2015-0117 12 Mar 2015
Barnet Enfield and Haringey Mental heal… Department of Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted (AI summary) The Department of Health acknowledges the concerns regarding mental health patient transfers and CRHTTs, but states responsibility lies with the local NHS. They highlight the Crisis Care Concordat and local Mental Health Crisis Action Plans.
Huseyin Erdogan
Historic (No Identified Response)
2015-0066 17 Feb 2015
Barnet Enfield and Haringey Mental Heal…
Mental Health related deaths
Concerns summary (AI summary) Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
John Ioannou
All Responded
2015-0012 6 Jan 2015
Department of Health and Social Care
Mental Health related deaths
Concerns summary (AI summary) There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.
Noted (AI summary) The Department of Health acknowledges the concerns about GPs monitoring medication collection for mental health patients, but cites practical and ethical challenges to implementing such a system. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.
Dale Proverbs
All Responded
2015-0010 6 Jan 2015
Department of Health and Social Care
Mental Health related deaths
Concerns summary (AI summary) Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.
Action Taken (AI summary) The Department of Health notes that Partnerships in Care (PIC) redrafted their policies to conform exactly to the 2008 Mental Health Act 1983 Code of Practice. Staff failure in this case to comply with the Mental Health Act Code of Practice is unacceptable.
Carla London
All Responded
2015-0003 6 Jan 2015
Department of Health and Social Care
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.
Action Planned (AI summary) The Department of Health has shared the coroner's report with NICE, so NICE can take the concerns into account in the development of its guideline on sepsis. NICE expects to publish its final guidance on this topic in July 2016.
Dean Elie
All Responded
2015-0001 6 Jan 2015
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary) The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing future deaths.
Noted (AI summary) The Department of Health acknowledges the concerns about ensuring patients with capacity attend medication reviews, but states there are no plans to extend mental health legislation and refers to the Mental Capacity Act for those lacking capacity.
Santosh Muthiah
All Responded
2014-0476 5 Nov 2014
Association of British Insurers Association of Manufacturers Of Domesti… Beko Plc +9 more
Product related deaths
Concerns summary (AI summary) The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.
Noted (AI summary) BSI Committees CPL/61 and PEL/33 reviewed the points raised and are submitting a proposal to the International Committee to add a warning about supply cords and portable socket-outlets to relevant appliances, and a new test for non-metallic material covering thermal insulation. AMDEA's Technical Manager on Refrigeration together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24. This proposal was placed before the BSI committee CPL61 and was accepted as a UK proposal for change at international level in 2014; the UK proposal was accepted by the International Electrotechnical Commission (IEC) meeting in Tokyo. The Society explains its role as a professional body for forensic science practitioners, noting that their reports are usually delivered directly to those who engaged them and may be sensitive or confidential. They state that forensic scientists are rarely involved in fire investigations unless they are serious, unexplained or suspicious, and that the fire service and/or police usually investigate. CFOA will engage proactively with DCLG to help develop the future IRS and the ease by which this type of information can be gathered, accessed and disseminated. CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do so. BIS will consider consistency of guidance and sharing of best practice as part of the independent review of consumer product recalls. The potential for a Code of Practice will also be considered as part of the independent review. BIS will continue to support AMDEA's Register my Appliance site.
Chloe Siokos
Historic (No Identified Response)
2014-0439 8 Oct 2014
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.
Graham Darby
Historic (No Identified Response)
2014-0367 24 Jul 2014
East London NHS Foundation Trust Family Mosaic Hackney Alcohol Recovery Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Michael Harrison
Historic (No Identified Response)
2014-0317 9 Jul 2014
Pinner and District Community Associati…
Other related deaths
Concerns summary (AI summary) Inadequate measures to treat ice in the car park created an unsafe environment.
Henry Marsh
All Responded
2014-0306 2 Jul 2014
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary) The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
Noted (AI summary) The Department of Health acknowledges the concerns about the Home Treatment Team's caseload and refers the Coroner to existing national guidance and resources for Crisis Home Treatment Teams. NHS England intends to map this best practice guidance on to the mental health intelligence network, but there is currently no set timeline.
Farres Ikken
Historic (No Identified Response)
2014-0310 2 Jul 2014
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.
Mark Duggan
All Responded
2014-0182 29 May 2014
Association of Chief Police Officers Coroner's Society Crown Prosecution Service +4 more
Police related deaths
Concerns summary (AI summary) Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted (AI summary) The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Michaela Christoforou
All Responded
2014-0285 25 May 2014
Care UK
Care Home Health related deaths
Concerns summary (AI summary) All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Action Planned (AI summary) Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.
Liam Coleman
Historic (No Identified Response)
2014-0312 25 May 2014
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary) There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.
Andre Matei
All Responded
2014-0089 25 Feb 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Noted (AI summary) The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention for future consideration.
James Sutton
Historic (No Identified Response)
2014-0090 24 Feb 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Simon McAndrew
Historic (No Identified Response)
2014-0067 19 Feb 2014
Central and North West London NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.
Adrian Cowan
Partially Responded
2014-0111 7 Feb 2014
Barnet Enfield and Haringey Mental Heal… North London Forensic Service
Mental Health related deaths
Concerns summary (AI summary) The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Action Taken (AI summary) Barnet, Enfield and Haringey Mental Health Trust has reviewed and updated the Trust’s resuscitation policy to include additional action to be taken in response to the “deteriorating patient”. They have also implemented regular assessments and practical sessions using a lifelike manikin, and conduct unannounced resuscitation scenarios across the Forensic wards.
Mone White
All Responded
2014-0031 21 Jan 2014
Department of Health and Social Care Northwick Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Noted (AI summary) The Secretary of State acknowledges the concerns, notes that guidance was already provided to relevant organisations, and refers to GMC guidance on information sharing. They consider that systems to ensure clinical advice is brought to the attention of treating clinicians should be addressed locally by the NHS Trust. The North West London Hospitals NHS Trust has developed and implemented a flagging system for patients under the care of specialist hospitals with specialist clinical requirements, in partnership with Consultant Paediatricians and the IT Department. A standard operating procedure supports the process and the system has been discussed widely within the Paediatric Directorate.
Wayne Broad
Partially Responded
2014-0020 17 Jan 2014
Association of Chief Police Officers Department of Health and Social Care G4S +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Noted (AI summary) The Secretary of State states that specialist substance misuse nurses may not be the most effective use of resources in all hospitals and that a specialist substance misuse nurse would not have changed the outcome for Mr Broad, referring to existing NICE guidance for alcohol use disorders.
Grace Mary Bates
All Responded
2014-0007 7 Jan 2014
Barnet and Chase Farm Hospitals NHS Tru… Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Noted (AI summary) A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week has been approved and an appointment is awaited. The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient outcomes and weekend services. The response emphasizes local organizations' responsibility for delivering high-quality care.
Roshan Abbas Ladak-Ebrahim
All Responded
2013-0278 5 Nov 2013
Department of Health
Community health care and emergency services related deaths
Concerns summary (AI summary) Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.
Noted (AI summary) The Department of Health acknowledges concerns about assessing self-harm risk and providing safety advice, referencing existing government action plans, NICE guidance, and GMC guidance on confidentiality and information sharing.
Mark Stephen Smith
Historic (No Identified Response)
2013-0268 21 Oct 2013
London Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary) Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.
Joseph Burrell
Partially Responded
2013-0194 5 Aug 2013
Harrow Council Traffic and Harrows Network Management …
Road (Highways Safety) related deaths
Concerns summary (AI summary) The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, making it unsafe to cross.
Action Taken (AI summary) Harrow Council, in partnership with TfL, completed the installation of new signal equipment and linking of signals via SCOOT (Split Cycle Offset Optimisation Technique) to improve traffic flow; they are now monitoring the performance and will review the feasibility of introducing a dedicated pedestrian phase.