West London

Coroner Area
Reports: 67 Earliest: Mar 2014 Latest: 5 Feb 2026

57% response rate (below 62% average).

Response Status
Responded 38 No Response 2 Historic 23 Pending 1
AI Classification
Action Taken 48%
Action Planned 24%
Noted 24%
Disputed 3%
Based on 29 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: -69 reports · -1pp response rate
vs national average: -16 reports · -5pp response rate
67 results
Sousse (Tunisia)
Historic (No Identified Response)
2017-0206 7 Jul 2017
ABTA Department for Transport Foreign, Commonwealth & Development Off… +1 more
Other related deaths
Concerns 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 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 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.
Richard Bull
Historic (No Identified Response)
2017-0154 10 May 2017
Apple
Product related deaths
Concerns 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 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 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
Unknown
22 Jul 2016
State Custody related deaths
Concerns 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
Unknown
11 Dec 2015
Care Home Health related deaths
Concerns 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 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 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
Home Office Practice Plc Nestor Primecare +2 more
Other related deaths
Concerns summary Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained medical staff, deficient medical assessments, and lack of comprehensive clinical records.
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 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
NHS Hillingdon Clinical Commissioning G… Central and North West London NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Neil Carter
All Responded
2014-0103 5 Mar 2014
Priory Group Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014
Serco National Offender Management Service HMP Wormwood Scrubs +1 more
State Custody related deaths
Concerns 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.
Angela Maguire
Partially Responded
2022-0164
NHS England Kingston Hospital NHS Trust
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative care discussions.
Action taken summary NHS England is working to establish Imaging Networks across England, aiming for 70% of networks to reach a 'Maturing' level by 2024/25, which will enable cross-site sharing of imaging history …
Mena Terefi
Historic (No Identified Response)
2022-0166
West London Mental Health NHS Trust NHS England
Mental Health related deaths Suicide (from 2015)
Concerns summary Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.