Misleading Information to Coroner

Concerns regarding a local council providing potentially misleading or incomplete information to a coroner about a death.

64 items 8 sources 3 inquiries
Strongest matches Browse by source
Watch Generate AI Report Export
Source spread

Where this theme appears

Misleading Information to Coroner has been flagged across 8 independent accountability sources:

4 inquiry recs 6 PFD reports 9 committee recs 4 PPO recs 4 IMB recs 3 Article 2 learning points 28 PHSO decisions 6 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

Browse by source

Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

30 — National protocol on duties relating to inquests
Morecambe Bay Investigation
Recommendation: A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement …
Gov response: 67. We accept this recommendation in principle. We will give further thought, with the Ministry of Justice and Chief Coroner’s Office, to whether an additional protocol would be helpful in guiding appropriate behaviour in relation …
Accepted
R68 — Consultant involvement in death certificates
Vale of Leven Inquiry
Recommendation: Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in completion of the death certificate wherever practicable.
Gov response: Section 4.1 of the Scottish Government's response introduces the chapter as focusing on professional standards and measures to govern death certification, including recommendation 68. However, the "Our current position" subsections within the provided text do …
Accepted
ETI-21 — Duty of Officials to Councillors
Edinburgh Tram Inquiry
Recommendation: Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to provide accurate reports to councillors to enable them to take …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted No update 2+ yrs
ETI-20 — Prohibition on Misleading Reports from ALEOs
Edinburgh Tram Inquiry
Recommendation: The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm's-length external organisation (ALEO) wholly owned by the local authority that is the promoter and owner of the …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted No update 2+ yrs
Timothy Clayton
11 Nov 2013 · London Inner (North)
Concerns: Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Responded
Marcus McGuire
23 Jun 2019 · Birmingham and Solihull
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Response (HM Prison and Probation Service): HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document.
Response (G4S): G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody …
Responded
Alex Blake
29 Jul 2019 · London Inner (South)
Concerns: Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Response (NMC): The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust …
Response (NHS Professionals): NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to …
Responded
Darren Goddard
09 Mar 2020 · South Wales Central
Concerns: Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Response (Dr Hopkins): The Health Board has agreed to use consistent terminology regarding sepsis and exclude reference to the word 'rarely' on the TRUS biopsy consent form. A single leaflet produced by the …
Responded
Roy Travers
08 Nov 2022 · Inner North London
Concerns: There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.
Response (Whittington Health NHS Trust): Whittington Health NHS Trust has provided feedback to the nurse who did not escalate the melaena and booked them on a course covering the deteriorating patient, with further training being …
Responded
Mark Beresford
25 Oct 2024 · Nottingham City and Nottinghamshire
Concerns: Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Response (HM Prison and Probation Service): HMP Ranby provides regular training and guidance to staff on the ACCT process, and guidance has been issued to staff to improve understanding of ACCT. A three-stage quality assurance process …
Responded
#2 —
Public Administration and Constitutional Affairs Committee
Recommendation: In May 2020, the PHSO reported to the Committee that it had experienced an increase of 13 per cent in demand compared to the previous financial year. Due to the introduction of a new digital casework management system, comparisons between …
Gov response: PHSO is open and transparent about the performance of the service we provide. The information we provided to the Committee in May 2020 was and is correct. Accordingly, the Ombudsman wrote to the Committee on …
Under Consideration
#11 —
Justice Committee
Recommendation: The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient by themselves to prevent large multi-handed inquests, where individuals’ and organisations’ reputations are at stake, from becoming adversarial.
Gov response: Whilst the Committee welcomed the Government’s steps to support the inquisitorial nature of inquests, it did not consider that these were enough to prevent large multi- handed inquests, where individuals’ and organisations’ reputations were at …
Under Consideration
#11 —
Foreign Affairs Committee
Recommendation: The FCDO has repeatedly given us answers that, in our judgement, are at best intentionally evasive, and often deliberately misleading. On Nowzad, they only admitted that the case had been in any way unusual when faced with the evidence of …
Under Consideration
#22 —
Public Administration and Constitutional Affairs Committee
Recommendation: The Committee was disappointed to learn that some of the data provided by the PHSO to inform the Committee’s PHSO Scrutiny 2020–21 Report had been revised unjustifiably ahead of this year’s inquiry, preventing easy comparability between reports. For the Committee …
Gov response: PHSO conducts a thorough review of all performance data on an annual basis. Data provided to the Committee is quality assured to the highest standard. We contracted a third-party provider to conduct the 2021 Staff …
Accepted
#9 —
Justice Committee
Recommendation: Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We …
Gov response: The Chief Coroner will however provide a detailed response to this recommendation.
Under Consideration
#8 —
Science, Innovation and Technology Committee
Recommendation: Several contributors to this inquiry expressed concern that the information provided to consumers before and after using a direct-to-consumer genomic test, as well as the advertising used to market direct-to-consumer genomic tests, did not do enough to address public misconceptions …
Gov response: Several areas being explored as part of MHRA’s public consultation, including the potential to introduce new classification rules for IVDs, will help to inform future policy on this recommendation.
Under Consideration
#22 —
Foreign Affairs Committee
Recommendation: UK nationals have been let down by the information shared by Ministers— actions which were counterproductive and may have contributed to less favourable conditions for an earlier release. Coherence and accuracy are vital not only in fairness to the families …
Gov response: 22. The Government accepts the fundamental importance of early identification and escalation of complex detentions, including arbitrary detention for diplomatic leverage. That is why the FCDO has adopted the task force approach recommended in the …
Accepted
#8 —
Public Accounts Committee
Recommendation: The Department’s lack of transparency fuelled accusations of political bias in the selection process.16 Furthermore, the Department’s statements to the press, issued after the National Audit Office’s report was published, referred to the report concluding that the selection process had …
Gov response: 1.1 The government disagrees with the Committee’s recommendation. 1.2 As the Committee will be aware and as set out in Treasury Minutes from December 2016 (recommendation 3b) wider government practice precludes the sharing of the …
Not Addressed
#5 —
Home Affairs Committee
Recommendation: Former Chief Constable Guildford was not informed ahead of giving oral evidence on 6 January that Microsoft Copilot AI had been used to generate the erroneous information about a match between West Ham and Maccabi Tel Aviv. On this basis …
Response Pending
P-003667 — South Tyneside and Sunderland NHS Foundation Trust
Mrs O complains that between 2017 and 2023 the Trust failed to inform her husband that his prostate cancer diagnosis was life-limiting and untreatable.
NHS in England Jul 2025
P-004785 — A practice in the Torbay area
Mr A complains a Practice in Paignton incorrectly completed his father’s death certificate, did not provide the amended certificate without cost and did not deal with his complaint in line with its own complaint procedure.
NHS in England Feb 2026
P-001720 — A practice in the Wirral area
Mr O complains the Practice gave him wrong information about his test results and about its planned course of treatment.
NHS in England Jan 2023
P-003908 — Epsom and St Helier University Hospitals NHS Trust
Dr U complains about the care and treatment her son received from a nurse at the Trust. She states the nurse gave misleading and inaccurate information about her son during meetings and failed to consider his best interests.
NHS in England Jul 2023
P-002626 — A practice in the North Yorkshire area
Mrs N complains that two organisations provided incorrect information to a mental health tribunal.
NHS in England May 2024
P-004230 — University Hospitals Birmingham NHS Foundation Trust
Mrs H complains about the treatment she received from University Hospitals Birmingham NHS Foundation Trust (the Trust). She says in 2016 she had a biopsy on her right lung, during the procedure the surgeon damaged her lung then the Trust provided inaccurate information in its response letter about who completed …
NHS in England Nov 2025
P-004371 — Lewisham and Greenwich NHS Trust
Mrs E complains about the care the Trust provided her father between March and April 2022. She says it delayed scanning to identify his cancer had spread, delayed moving him to palliative care and discharging him, asked her and her brother to take a COVID-19 test and falsely claimed to …
NHS in England Nov 2025
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains while his father, Mr S, was in University Hospitals Birmingham NHS Foundation Trust (the Trust), he was sexually assaulted by another patient while the staff knew the patient posed a risk. He also complains in the Trust response, it supplied false and misleading information.
NHS in England Jan 2026
P-001218 — Children and Family Court Advisory and Support Service
Mr A complained that Cafcass incorrectly told a court that he had been convicted of assaulting his ex-wife, which he says did not happen.
UK Government Not Upheld Nov 2021
P-002047 — Northumbria Healthcare NHS Foundation Trust
Mrs O complains the Trust did not do the autopsy on her father’s body correctly because details on the report were wrong.
NHS in England Jun 2023
P-002311 — Mid Yorkshire Teaching NHS Trust
Mrs I complains the Trust misdiagnosed her husband with lung cancer when he was admitted with covid pneumonia. She also says he was discharged when he was not able to walk or talk and was confused.
NHS in England Nov 2023
P-003153 — A practice in the Oadby and Wigston area
Mr A complains the Practice failed to visit his brother after his discharge from hospital in October 2022 until after he died in December 2022. Mr A also says the Practice failed to record appropriate information when certifying his brother’s death.
NHS in England Not Upheld Nov 2024
P-003275 — North East Ambulance Service NHS Foundation Trust
Mrs G complains about the care and treatment North East Ambulance Service NHS Foundation Trust provided to her husband, Mr G, when he fell ill on 20 December 2023. She complains it took staff too long to get him into the ambulance. She also complains the staff involved have given …
NHS in England Jan 2025
P-003443 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs A complains that in October 2022 the Trust gave confusing information about her husband’s diagnosis, did not drain his kidneys and gave him oral morphine which caused his organs to shut down.
NHS in England Mar 2025
P-003742 — Portsmouth Hospitals University NHS Trust
Ms M complains of delays in the Trust’s identification of her father’s cancer and action once his stent had failed, along with a miscommunication of him being cancer-free.
NHS in England Not Upheld Aug 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complains about the care and treatment her father, Mr D, received from the Trust in April 2020. She says the Trust failed to diagnose and treat him appropriately after surgery, mismanaged his sepsis, overlooked signs of blood clots, and did not refer his case to the coroner despite …
NHS in England Sep 2025
P-004132 — Oxford University Hospitals NHS Foundation Trust
Dr A complains about aspects of care and treatment her mother, Mrs A, received when she choked on her food at the Trust. She is also concerned about how the Trust investigated the incident and completed the death certificate.
NHS in England Upheld Oct 2025
P-004707 — A practice in the Chesterfield area
Mr L complains about aspects of care provided to him by a Practice in the Derbyshire area. He complains the Practice did not provide clear information regarding why only part of his skin condition was recorded on his records, a doctor at the Practice deliberately misled him during two consultations …
NHS in England Jan 2026
P-002342 — Hampshire Hospitals NHS Foundation Trust
Mr T complains the Trust incorrectly told his wife her left breast implant had ruptured. He complains the Trust told her she needed urgent surgery but did not do the surgery.
NHS in England Upheld Sep 2023
P-002497 — Barts Health NHS Trust
Mr L complains the Trust misdiagnosed him with a sexually transmitted disease in February 2022 and about the length of time it took to respond to his complaint.
NHS in England Mar 2024
P-002553 — Stockport NHS Foundation Trust
Mr D complains about the care he had after surgery and that nurses did not clean his wound for two days which led to a severe infection. He also complains the Trust wrongly told him he had cancer.
NHS in England Apr 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complains that clinicians failed to act on her mother’s high risk of falls in December 2022. She says her mother had two serious accidents and sustained significant injuries. Miss A also believes documentation was falsified.
NHS in England Sep 2024
P-003069 — The Princess Alexandra Hospital NHS Trust
Mrs W complains about the care her father received in hospital, poor communication before he died and the completion of his death certificate.
NHS in England Oct 2024
P-003062 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complains the Trust discharged her uncle inappropriately and without a zimmer frame, which resulted in him being readmitted the same day. She also complains the Trust completed a falls assessment incorrectly and it provided her with inaccurate information about his mobility.
NHS in England Upheld Oct 2024
P-003165 — Guy's and St Thomas' NHS Foundation Trust
Mr L complains about the care a physiotherapist gave to his mother in November 2022. He complains they failed to move his mother with the assistance of two people and lied about a fall.
NHS in England Nov 2024
P-004147 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss U has raised concerns about the care her father, Mr U, received from the Trust. She highlights delays in administering aspirin following his stroke, inconsistent information about his diagnosis, an undocumented early withdrawal from an induced coma, and conflicting accounts provided during treatment and in the Trust’s complaint response.
NHS in England Oct 2025
P-002056 — A dental practice in the Croydon area
Mrs O complains the Practice gave her misleading information before she had treatment. She says if she had known the truth, she would not have gone ahead with the treatment.
NHS in England Jun 2023
P-003894 — The Royal Wolverhampton NHS Trust
Mr R complains about the Trust's care and treatment of his late wife from 2018. He says it did not give his wife or daughter genetic testing, it recorded his wife's cancer incorrectly on an official register, it did not give him information he asked for and its investigation into …
NHS in England Jun 2023
21-011-697 — Surrey County Council
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
LGO (Local Government & … Other Categories Upheld Mar 2022
21-007-703 — West Northamptonshire Council
Summary: Mr B says the Council misled the Planning Committee which influenced its decision to grant planning permission. Although officers failed to correct one piece of information at the Committee meeting there is no evidence this affected the final decision.
LGO (Local Government & … Planning Upheld Apr 2022
22-006-656 — London Borough of Croydon
Ms X complains about the council staff misleading the criminal justice system.
LGO (Local Government & … Children S Care Services Sep 2022
21-018-329 — Surrey County Council
Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. …
LGO (Local Government & … Other Categories Upheld Apr 2022
24-006-084 — London Borough of Richmond upon Thames
Summary: We will not investigate Ms X’s complaint about a report the Council prepared for the court because we cannot investigate complaints about court proceedings.
LGO (Local Government & … Education Sep 2024
25-011-009 — London Borough of Lambeth
Summary: We will not exercise discretion to investigate this complaint about the Council’s officers giving misleading information to the BBC in a broadcast in July 2024. This complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest that Mr X could not have …
LGO (Local Government & … Other Categories Sep 2025
Back to all themes