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
70 results
Natasha Ednan-Laperouse
Partially Responded
2018-0279 8 Oct 2018
Department for the Environment, Food an… Medicines and Healthcare products Regul… Pfizer +1 more
Other related deaths
Concerns summary (AI summary) Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic reactions. Additionally, the needle length and adrenaline dose of Epipens may be inadequate for treating anaphylactic reactions.
Action Planned (AI summary) The MHRA has already undertaken a review of adrenaline auto-injectors, progressed this within Europe, resulting in improved training, additional risk minimisation measures and factual disclosures within the product information. They are also undertaking a rigorous evaluation of the clinical study data for each brand of adrenaline auto-injector and will ensure any necessary measures are taken to increase effectiveness. The Department is undertaking an urgent review of allergen information provision for food which is pre-packed for direct sale, with a consultation on policy options planned for early in the new year and any needed legislation to follow as soon as possible. The FSA has been working with local authorities in Lancashire on a pilot scheme to improve the notification of incidents between businesses, local authorities and the NHS.
Sneh Chaudhry
Historic (No Identified Response)
2018-0182 15 Jun 2018
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Kevin Freely
Historic (No Identified Response)
2018-0180 7 Jun 2018
Care Quality Commission Skillsforcare Home Office
Community health care and emergency services related deaths
Concerns summary (AI summary) Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
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.
Pamela Craigie
Partially Responded
2017-0279 27 Sep 2017
Advinia Healthcare Ltd London Borough of Hounslow
Care Home Health related deaths
Concerns summary (AI summary) The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local authority. Delays in urgent assessments and unclear interim safety plans for high-risk residents pose a significant risk.
Action Taken (AI summary) The Company has reviewed its Falls Prevention Policy, clarifying the 1:1 care protocol and updating risk assessments. The revised policy was issued to all homes in October 2017.
Sousse (Tunisia)
Historic (No Identified Response)
2017-0206 7 Jul 2017
ABTA Civil Aviation Authority Department for Transport +1 more
Other related deaths
Concerns summary (AI summary) Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.
Alaanuloluwa Joseph
Historic (No Identified Response)
2017-0189 14 Jun 2017
Hillingdon Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.
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.
Richard Bull
Historic (No Identified Response)
2017-0154 10 May 2017
Apple
Product related deaths
Concerns summary (AI summary) There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.
Nihad Ousta
Historic (No Identified Response)
2016-0378 25 Oct 2016
West London Mental Health Trust
Mental Health related deaths
Concerns summary (AI summary) There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.
Hunter Macmillan
Historic (No Identified Response)
2016-0375 24 Oct 2016
Chelsea and Westminster Hospitals NHS T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected sepsis.
Olawale Adelusi
Historic (No Identified Response)
22 Jul 2016
METROPOLITAN POLICE SERVICE
State Custody related deaths
Concerns summary (AI summary) There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
Margaret O’Brien
Historic (No Identified Response)
11 Dec 2015
CARE UK
Care Home Health related deaths
Concerns summary (AI summary) Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
Ian Morley
Historic (No Identified Response)
2015-0320 17 Aug 2015
Adult Social Services Greenrod Place
Other related deaths
Concerns summary (AI summary) A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Blaise Farry
Historic (No Identified Response)
2015-0269 30 Jun 2015
HMP WORMWOOD SCRUBS
State Custody related deaths
Concerns summary (AI summary) Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.
Brian Dalrymple
Partially Responded
2014-0410 18 Sep 2014
GEOAmey Nestor Primecare Serco +2 more
Other related deaths
Concerns summary (AI summary) The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure to act on recorded observations, inadequate medical visits to segregated detainees, and the absence of a comprehensive clinical record system.
Noted (AI summary) GEO Group states that as the contract for Harmondsworth IRC passed to Mitie, they cannot take action regarding working practices there. However, they will consider lessons learned from the inquest for their other operations.
June Rose
Historic (No Identified Response)
2014-0267 11 Jun 2014
Royal College of General Practitioners
Community health care and emergency services related deaths
Concerns summary (AI summary) A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.
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.
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014
HMP Wormwood Scrubs Metropolitan Police National Offender Management Service +1 more
State Custody related deaths
Concerns summary (AI summary) Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.