West London

Coroner Area
Reports: 70 Earliest: Mar 2014 Latest: 5 Feb 2026

59% response rate (below 63% average).

Response Status
Responded 41 No Response 1 Historic 25 Pending 1
AI Classification
Action Taken 39%
Action Planned 39%
Noted 21%
Disputed 1%
Based on 67 classified responses
Top Categories
Hospital Death (Clinical Procedure… (19) State Custody related deaths (12) Suicide (from 2015) (12) Other related deaths (11) Mental Health related deaths (7)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: -68 reports · +2pp response rate
vs national average: -14 reports · -4pp response rate
Clear 33 results
Bethan Harris
All Responded
2020-0133 22 Jun 2020
St. George’s University Hospitals NHS F…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.
Action Taken (AI summary) The Trust has taken several steps including reinforcing the importance of accurate and contemporaneous record keeping, reviewing the administration of medication to patients, sharing learning, and ensuring patients are adequately monitored during their stay. Mandatory training will be ongoing.
Matthew Williamson
All Responded
2019-0349 15 Oct 2019
West London Mental Health Trust
Mental Health related deaths
Concerns summary (AI summary) Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.
Action Taken (AI summary) The Trust has amended operational policies to include sections on strengthening family involvement and has mandated Carer Awareness and Triangle of Care training for Ealing PCMHS staff. They are also taking steps to establish a Carers Council.
John Thorp
All Responded
2019-0067 26 Feb 2019
London North West University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.
Action Taken (AI summary) The Trust has introduced a new, standardised prescription chart with a section for TED stockings, including a venous thromboembolism risk assessment. Nurses must sign and date the chart daily to confirm they have checked the fitting and skin integrity. Memos were sent to staff and the information circulated Trust-wide via newsletters and screen savers.
Henry Curtis-Williams
All Responded
2018-0397 19 Dec 2018
Norfolk and Suffolk NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.
Action Planned (AI summary) The Trust will be using the case in learning via patient safety newsletter and practice education teams. The Trust issued an internal alert to inpatient wards directing reflection on processes where information is received from differing sources.
John O’Meara
All Responded
2018-0012 10 Jan 2018
HMP Wormwood Scrubs
State Custody related deaths
Concerns summary (AI summary) Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Action Taken (AI summary) Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff; notices have been attached to all cell doors in the First Night Centre; the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region, including HMP Wormwood Scrubs, which will be provided with a total of seven dog handlers, with both passive and active search and patrol dogs.
Alice Gibson-Watt
All Responded
2017-0163 18 May 2017
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.
Action Taken (AI summary) NHS England outlines existing initiatives to improve perinatal mental health and the care of acutely unwell patients in mental health settings. This includes expanding access to specialist perinatal mental health care, rolling out the Recognising and Managing Patients Psychiatric Settings (RAMMPS) course, and supporting the Physical Health SMI CQUIN.
Rosemary Oladejo
All Responded
2014-0203 22 Apr 2014
Central and North West London NHS Found… NHS Hillingdon Clinical Commissioning G…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Action Planned (AI summary) Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors in July 2014 and ensure practice pharmacists review and improve medicines reconciliation processes starting in July 2014. Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance of communication. They will also take this to the Mental Health Partnership Board to highlight the communication lessons.
Neil Carter
All Responded
2014-0103 5 Mar 2014
Care Quality Commission Priory Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Action Planned (AI summary) The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat and deliver a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, with a national report expected in the autumn of 2014. The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring visits, 'flash' meetings and monthly staff meetings to improve communication and patient care.