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
Clear 50 results
Jacqueline Aarons
All Responded
2025-0576 10 Nov 2025
Department of Health and Social Care
Care Home Health related deaths
Concerns summary A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Action taken summary The Department for Health and Social Care acknowledges the concerns but states that these matters are more appropriately addressed by NHS England directly, who will provide a full and comprehensive …
Brian Lloyd
All Responded
2025-0557 3 Nov 2025
High Meadows Care Home
Care Home Health related deaths
Concerns summary Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
Action taken summary High Meadows Care Home has updated its catheterisation policy, created and disseminated a new Catheter Emergency and Escalation Protocol, and provided staff training. They also reconfigured their tele
William Puplett
All Responded
2025-0526 10 Oct 2025
International Academies of Emergency Di…
Emergency services related deaths (2019 onwards)
Concerns summary Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
Action taken summary The IAED states the emergency medical dispatcher was compliant with existing protocol and correctly assigned the appropriate dispatch code. It argues the caller was asked about special equipment and t
Sidi Bojang
All Responded
2025-0436 1 Aug 2025
Department of Health and Social Care
Suicide (from 2015)
Concerns summary Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Action taken summary NHS England has strengthened 24/7 mental health liaison services in all Type 1 Emergency Departments and published the Men's Health Strategy. They are also working towards consultant-led assessments a
Robert English
All Responded
2025-0380 25 Jul 2025
Transport for London Rail Safety Board Department of Transport
Railway related deaths
Concerns summary Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and increase the risk of collision.
Action taken summary Transport for London has already updated its operational rules for track searches and commenced testing a prototype high-lumen lighting rig for train cabs to improve night-time visibility. They have a
Leia Sampson-Grimbly
All Responded
2025-0381 25 Jul 2025
Department of Health and Social Care Tavistock and Portman NHS Foundation Tr…
Child Death (from 2015) Suicide (from 2015)
Concerns summary Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Action taken summary The Trust noted the concern about long waiting lists for Gender Dysphoria clinics, explaining that NHS England has been unable to commission sufficient capacity due to a lack of specialist …
Evelyn Chancellor
All Responded
2025-0382 25 Jul 2025
Ashton Lodge Care Home
Care Home Health related deaths
Concerns summary Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Action taken summary Ashton Lodge Care Home has already implemented revised staffing matrices and a structured rota for additional staff during peak times. They have also delivered refresher training on falls prevention a
Champagauri and Dipak Bhatt
All Responded
2024-0677 6 Dec 2024
North Yorkshire Council Hotpoint UK Appliances Limited Association of Manufacturers of Domesti… +4 more
Product related deaths
Concerns summary Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and inconsistent risk assessment methodology.
Action taken summary Hotpoint UK Appliances Ltd has undertaken internal testing of condensate pump components and found no safety defect. They are also actively engaged in the London Fire Brigade/AMDEA digital identificat
Kingsley Imafidon
All Responded
2024-0554 11 Oct 2024
Royal College of Pathology Royal College of Radiologists British Society of Gastroenterology +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.
Action taken summary Homerton University Hospital has reviewed and updated its Elective Liver Biopsy Standard Operating Procedure (SOP) to include specific guidance on discussion with haematology and individualised post-o
Maria de Ceita
All Responded
2024-0455 31 Jul 2024
North Middlesex University Hospital NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a fatal fall. This highlights a systemic failure in managing elderly patient fall risks.
Mia Janin
All Responded
2024-0103 22 Feb 2024
Jewish Free School
Child Death (from 2015) Suicide (from 2015)
Concerns summary Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create a continued risk of future deaths.
O’Shea Dover
All Responded
2024-0067 6 Feb 2024
Department of Health and Social Care Association Ambulance Chief Executives
Child Death (from 2015) Emergency services related deaths (2019 onwards)
Concerns summary National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.
Paz Ogbe-Millar
All Responded
2024-0060 5 Feb 2024
West Hertfordshire Hospitals NHS Trust
Railway related deaths
Concerns summary Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Peter Carr
All Responded
2023-0403 13 Oct 2023
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout their inpatient stay.
Lamont Roper
All Responded
2023-0381 7 Sep 2023
Metropolitan Police Service
Other related deaths
Concerns summary Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
Sophie Williams
All Responded
2023-0079Deceased 27 Feb 2023
Barnet Enfield and Haringey Mental Heal… Tavistock and Portman NHS Foundation Tr… NHS England
Alcohol, drug and medication related deaths
Concerns summary Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and insufficient mental health support.
Molly Russell
All Responded
2022-0315 13 Oct 2022
Department for Culture, Media and Sport Twitter International Company Snap Inc +2 more
Child Death (from 2015) Suicide (from 2015)
Concerns summary Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through algorithms and unrestricted access.
Sean Ennis
All Responded
2022-0054 21 Feb 2022
London Borough of Brent Network Homes Housing Association and B…
Other related deaths
Concerns summary Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of person-centred risk assessments and accreditation.
John Jennings
All Responded
2020-0257 26 Nov 2020
Ministry for Housing and Local Governme…
Emergency services related deaths (2019 onwards) Other related deaths
Concerns summary Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.
Neville Bardoliwalla
All Responded
2020-0258 26 Nov 2020
Department of Health and Social Care
Other related deaths Suicide (from 2015)
Concerns summary A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.
Sonny Parmar
All Responded
2020-0075 24 Mar 2020
Barnet Council
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving the school.
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.
Priscilla Tropp
All Responded
2019-0213 24 Jun 2019
Govia Thameslink Railway Office of Rail and Road Department for Transport
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.