West London
Coroner Area
Reports: 70
Earliest: Mar 2014
Latest: 5 Feb 2026
59% response rate (below 63% average).
Paul Hutchinson
Response Pending
2026-0223
Care Quality Commission
Local Government Association
Minister for Housing Communities and Lo…
+1 more
Concerns summary (AI summary)
Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable residents at risk due to a lack of standardised staff training and comprehensive fire risk assessments.
Kallum Reed
All Responded
2026-0061
5 Feb 2026
Department of Health and Social Care
West London NHS Trust
Suicide (from 2015)
Concerns summary (AI summary)
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Noted
(AI summary)
• The Trust is the provider for adult ASD assessments in Ealing.
• When this service was established in 2021, it was modelled upon historical trends in activity referred to providers outside North West London, and commissioned and resourced by North West London ICB to complete 86 assessments per year.
• In the last three full financial years against this target, we delivered 547 assessments (212%), however demand continued to grow leading to a considerable backlog of patients awaiting diagnostic assessment experiencing unacceptable delays.
Lajos Mandrik
Response Pending
2026-0219
4 Jan 2026
South West London and St George’s Menta…
Concerns summary (AI summary)
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
Mohamed Abdisamad
All Responded
2025-0644
28 Dec 2025
Department for Health and Social Care, …
Child Death (from 2015)
Concerns summary (AI summary)
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Noted
(AI summary)
MHCLG acknowledges the concerns but states that the Department of Health and Social Care is the lead department and has provided a comprehensive response. MHCLG will liaise with DHSC regarding non-statutory measures. The Department of Health and Social Care is liaising with other government departments and plans to engage with stakeholders regarding non-statutory measures to improve patient safety in the area of non-therapeutic male circumcision. They highlight existing guidance and resources available.
Samuel Stewart
Partially Responded
2025-0574Deceased
12 Nov 2025
HMP Wormwood Scrubs
Ministry of Justice
Practise Plus Group
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.
Action Planned
(AI summary)
HMP Wormwood Scrubs has reminded all managers on the IFSL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings. Practice Plus Group outlines the process they follow when a patient on the Independent Substance Free Living unit has a positive drug test result, including referral to the clinical SMS team and the Substance Misuse Non-Medical Prescriber for assessment and a clinical plan. Communication processes are in place between Forward Trust, the prison and healthcare.
Ella David-Fong
All Responded
2025-0442
30 Jun 2025
CGL (Ealing RISE)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.
Noted
(AI summary)
CGL Ealing RISE will provide leaflets and website information about consent and confidentiality at the commencement of treatment, addressing how families can share concerns without breaching confidentiality, as well as an alternative point of contact in the organisation. The response explains Change Grow Live's confidentiality policy, including when information can be shared and how families can stay involved while respecting privacy.
Adam Ankers
Response Pending
2026-0217
16 Apr 2025
Association of Ambulance Chief Executiv…
Cardiac Risk in the Young (CRY)
Department of Health and Social Care (D…
+10 more
Concerns summary (AI summary)
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
1 response
from Resuscitation Council UK
Jonathan Hamer
All Responded
2025-0184
10 Apr 2025
South West London and St George’s Hospi…
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Action Taken
(AI summary)
The Trust has reviewed communication processes, including updating contact information on the website and care plans. They also revised team huddle agendas and implemented a standardized huddle directive across all community teams to improve zoning discussions, escalation procedures, and risk review, effective June 1, 2025.
Isaiah Olugosi
All Responded
2025-0106
24 Feb 2025
HMP Wormwood Scrubs
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Action Taken
(AI summary)
HMPPS expresses condolences and notes the concerns raised. The prison has addressed phone line issues ensuring the prison can be called at any time and that this is regularly tested. The Governor has ordered the external intercom system units to be removed.
Liam Allan
All Responded
2025-0132
30 Jan 2025
Kingston Council
Lambeth Council
Lewisham Council
+15 more
Police related deaths
Concerns summary (AI summary)
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Noted
(AI summary)
The London Fire Brigade has made significant changes to its radio system following the Grenfell Tower Inquiry, improving communication interoperability. They have also installed throwline boards, provided throwline training to businesses and parks patrols, opened a water safety training room, and strengthened operational working with Surrey Fire and Rescue Service. The National Fire Chiefs Council highlights the Fire Control Fire Standard and Guidance, the Multi-Agency Information Transfer (MAIT) system, and ongoing liaison with London Fire Brigade to ensure learning is captured and shared. They support fire and rescue services to improve the effectiveness and maximize the use of digital systems and this is a key priority for them in the Fit for the Future strategic plan. The London Borough of Barking and Dagenham will undertake a survey and asset mapping of waterbodies and riverside locations, assess sites using risk assessment criteria, standardise safety equipment, and implement a structured inspection and maintenance programme. They will advocate for enhanced inter-agency communication. The London Borough of Havering will give further consideration to the lighting of life buoys at inland bodies of water, ensure new buoyancy aids meet British Standards and require white stripes, and consider including a policy for developers to provide and maintain lifesaving equipment. They consider communication between emergency services to be a matter for the emergency services to address. The City of London acknowledges the concerns raised. The text describes various procedures and resources in place for managing incidents and ensuring safety, without stating a change in policy.
James Keen
All Responded
2025-0140
2 Jan 2025
Revon Healthcare
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.
Action Taken
(AI summary)
Support workers received additional physical health monitoring training, vital signs equipment was verified as functional, and community teams were engaged regarding residents with physical health concerns. New support workers receive a 2-week induction period and annual mandatory training.
James Alderman
All Responded
2024-0707
13 Dec 2024
BSI Group
Department of Health and Social Care
NHS England
+1 more
Child Death (from 2015)
Product related deaths
Concerns summary (AI summary)
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.
Action Planned
(AI summary)
The Department is reviewing information on the Better Health - Start for Life website regarding the safe use of baby carriers to ensure it is sufficiently prominent. They are also considering ways to supplement the content and engaging with key stakeholders to ensure the messaging is correct regarding the use of baby carriers and breastfeeding. NHS England acknowledges the need for clearer guidance on safe sling use and will work to improve the visibility and linking of existing resources on NHS.UK. They have referred the issue to NICE for consideration and passed details to UNICEF-UK. Several charities have agreed to advise parents that hands-free breastfeeding using slings and carriers is unsafe and should not be attempted. The Lullaby Trust is funding research and will convene a roundtable to agree simpler, consistent messaging for parents and stakeholders on safe sling and carrier use. OPSS is aware that Merton Council Trading Standards are investigating the specific product involved in the death, focusing on its compliance with safety standards. OPSS will also bring any updates to Government or NHS advice regarding infant safety in slings to the attention of trade associations and review the designation of the voluntary standard.
Terence Gillard
All Responded
2025-0264
5 Nov 2024
Department for Transport
London Borough of Hounslow
Transport for London
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are uncertain and significantly delayed.
Noted
(AI summary)
TfL intends to implement a permanent pedestrian crossing scheme at the A4/Jersey Road junction in Hounslow by 2026, including signal-controlled crossings. In the interim, temporary customer information signage warning pedestrians to take care when crossing the road will be installed by January 2025. The Department for Transport states that Transport for London (TfL) is responsible for traffic management on its roads, including the pedestrian crossing at issue. The DfT says no consent is required from the Department to enable TfL to make changes to this site, and funding will come from TfL revenue sources. The London Borough of Hounslow is working with TfL to improve traffic conditions on the A4, especially for vulnerable road users. Proposals are being considered for signal-controlled crossings for pedestrians and cyclists across the A4 and Jersey Road, with construction planned for 2026-27, along with interim temporary signage.
Wessam al Jundi
All Responded
2025-0377
25 Oct 2024
Department of Health & Social Care
Department of Housing, Community and Lo…
HSE
Accident at Work and Health and Safety related deaths
Product related deaths
Concerns summary (AI summary)
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient for this accelerated disease, risking future deaths.
Noted
(AI summary)
The HSE is publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. They are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks. The Worktop Fabricators Federation provides a 'state of the art' positioning statement on silica dust risks associated with quartz worktops, highlighting the need for safe working environments and suggesting potential market controls. The Agglomerated Stone Manufacturers Association highlights existing efforts to promote safety and calls for governmental involvement, suggesting clear rules and/or a licensing program for fabricators. MHCLG is requesting an extension and states that the concerns fall within the remit of the HSE, offering to provide a formal response explaining the limitations of MHCLG's policy remit. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE.
Frank Ospina
All Responded
2025-0338
25 Oct 2024
Home Office
Mitie
NHS England
State Custody related deaths
Concerns summary (AI summary)
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit denied a detainee physical contact and private conversation with family.
Action Planned
(AI summary)
NHS England plans to revise Detention Services Order 09/2016, Rule 35 assessments towards a multidisciplinary approach to safeguarding and vulnerability management in Immigration Removal Centres, and will jointly develop a stakeholder engagement session with the Home Office to share the revised requirements with IRC providers and operators. The Home Office is developing an interim update to its Rule 35 guidance, strengthening monitoring in detention, and implementing a 'Prevention of future deaths in immigration detention strategy'. Progress will be reported through the MBDC governance structures. Mitie Care and Custody has implemented a revised Standard Operating Procedure to prevent "closed visits" and has introduced a website translation and accessibility service called 'Recite' across its immigration removal centres.
Samsam Ateye
All Responded
2024-0662
3 Sep 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
Noted
(AI summary)
NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports.
Matthew Braben
No Identified Response CC
2024-0423
1 Aug 2024
His Majesty’s Prison and Probation Serv…
Ministry of Justice
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
David Siirak
All Responded
2024-0174
7 Mar 2024
Central and North West London NHS Found…
Other related deaths
Concerns summary (AI summary)
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Action Taken
(AI summary)
The Trust has taken action to improve staff training in emergency response, including additional in-situ simulation sessions and building a simulation room. Learning from simulations is shared via team meetings and presented to the Resuscitation and Deteriorating Patient Committee.
Tom Sweeting
All Responded
2024-0014
9 Jan 2024
West London NHS Trust
Suicide (from 2015)
Concerns summary (AI summary)
Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Action Taken
(AI summary)
The Trust has provided feedback to improve the completion of Trust templates, implemented a developmental program and supervision structures, and undertaken three audit cycles since April 2023 regarding self-harm assessments. A quarterly Mortality and Morbidity meeting has been introduced for liaison psychiatry teams, and learning from incidents is now incorporated into an annual team development program.
Denise Porter
Historic (No Identified Response)
2023-0548
21 Dec 2023
Oxleas NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI summary)
The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and an inadequate care plan.
Jack Zarrop
All Responded
2023-0362
2 Oct 2023
Home Office
National Police Chief’s Council
NHS England
Suicide (from 2015)
Concerns summary (AI summary)
Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.
Noted
(AI summary)
NHS England will ensure all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment and regional teams will be asked to give assurance at a meeting planned for June 2024, that the proposed action has been delivered and agency and bank staff have timely access to ACCT training. The NPCC clarifies that Custodial Nurse Practitioners (CNPs) are qualified and trained to work in police custody, with appropriate clinical support and supervision, according to the National Healthcare Specification. They assert the 2003 Home Office circular is outdated and the current healthcare model for police custody is robust. The Home Office states that Home Office Circular 020/2003 is no longer extant and therefore they propose to take no action in response to the report. They note the NPCC response regarding the National Healthcare Specification for police custody and NHS England's response regarding training of prison healthcare staff in the ACCT process.
Jacqueline Smith
Partially Responded
2023-0304
21 Aug 2023
Central and North West London Mental He…
Forward Trust
Hillingdon Council
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable tenant without effective assistance.
Action Taken
(AI summary)
The London Borough of Hillingdon has implemented a Hoarding Panel with representatives from various teams, provides training to officers to recognize and support residents that hoard, and refers complex cases to MARAC while avoiding enforcement action.
John Coles
All Responded
2023-0271
24 Jul 2023
Heathrow Airport
Other related deaths
Concerns summary (AI summary)
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures and oversight.
Action Planned
(AI summary)
HAL will commission an independent assessment of potential mitigation measures relating to visual clutter and airside vehicle conspicuity, develop new training materials for airside drivers, and amend the Operational Safety Instruction relating to temporary vehicle permits; with a target implementation date of April 1, 2024.
Gunapathyammah Ragnanathan
All Responded
2023-0087Deceased
13 Mar 2023
Lean on Me Care Agency
Care Home Health related deaths
Concerns summary (AI summary)
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.
Action Planned
(AI summary)
The agency has contracted training providers and a consulting agency to support ongoing training, including RQF courses for care workers. They are also recruiting more field care supervisors to improve shadowing and appraisal of new care workers.
Lance Walker
Historic (No Identified Response)
2023-0062Deceased
19 Jan 2023
Department for Education
Department of Health and Social Care
London Borough of Ealing
+2 more
Other related deaths
Concerns summary (AI summary)
The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training and staffing. Additionally, there is no standard referral form, risking missed vital information for supported housing placements.