Misleading Information to Coroner
Concerns regarding a local council providing potentially misleading or incomplete information to a coroner about a death.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
5 inquiry recs
6 PFD reports
13 committee recs
4 PPO recs
4 IMB recs
3 Article 2 learning points
28 PHSO decisions
6 LGO/SPSO decisions
4 CJINI reports
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.
Inquiry recommendations(5)
82 — Metropolitan Police investigation into Lambeth Council
Recommendation: The Metropolitan Police Service should consider whether there are grounds for a criminal investigation into Lambeth Council's actions when providing information to the coroner about the circumstances surrounding LA-A2's death.
No response yet
30 — National protocol on duties relating to inquests
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 in part
R68 — Consultant involvement in death certificates
Recommendation: Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patient’s care is involved in the completion of the death certificate wherever practicable, and that such involvement is clearly recorded in the patient …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
ETI-21 — Duty of Officials to Councillors
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: The Council’s relationship with its Arm-Length External Organisations (ALEOs) is outlined in the Tram Inquiry report and there are two recommendations (20 and 21) that relate to misleading the authority, scrutiny and challenge and the …
Accepted
ETI-20 — Prohibition on Misleading Reports from ALEOs
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: The Council’s relationship with its Arm-Length External Organisations (ALEOs) is outlined in the Tram Inquiry report and there are two recommendations (20 and 21) that relate to misleading the authority, scrutiny and challenge and the …
Accepted
Prevention of Future Deaths reports(6)
Timothy Clayton
Concerns: Kent Police improperly asked the deceased's family to make a decision on organ donation that is legally the coroner's responsibility. A police officer subsequently subverted the coroner's judicial decision by pressuring the grieving family.
Response: • Senior Investigating Officers in Kent and Essex Police have been reminded of national guidance on homicide and major incident investigation. • An urgent review will be conducted to assess … (AI summary)
Pending
Marcus McGuire
Concerns: The coroner identifies deficiencies in ACCT plans from the absence of a single case manager, affecting care and follow-up. Concerns were also raised about a disparity between evidence and inspection findings on implementing single case management at HMP Birmingham.
Response (HM Prison and Probation Service): • HMP Birmingham has trained additional case managers to improve consistency in single case management and reduce caseloads. • The prison has introduced daily monitoring and monthly reviews of single … (AI summary)
Response (G4S): • G4S stated that decisions regarding actions at HMP Birmingham are not within its remit, as the prison is now operated and managed by HMPPS. • G4S indicated that it … (AI summary)
Responded
Alex Blake
Concerns: The coroner raised concerns regarding the reliability of observations and recorded evidence by three staff members, noting inconsistencies in their accounts and suggesting that observations may not have been performed or that false evidence was provided.
Response (NMC): • The NMC passed the report concerning two registered nurses to its Fitness to Practise team for further investigation. • The Employer Link Service contacted the trust and NHS Professionals … (AI summary)
Response (NHS Professionals): • NHS Professionals obtained all information relating to the case from South London & Maudsley NHS Foundation Trust upon receipt of the report. • The Interim Clinical Governance Director and … (AI summary)
Responded
Darren Goddard
Concerns: Misleading patient information on TRUS elective surgery risks and premature post-operative discharge hindered early sepsis recognition. Subsequent delays occurred in triage escalation, timely treatment, and Critical Care admission.
Response (Dr Hopkins): • A single, standardised British Association of Urological Surgeons (BAUS) leaflet is now used for discharge advice. • Ongoing sepsis training for medical and nursing staff has been reinstated, though … (AI summary)
Responded
Roy Travers
Concerns: Concerns were raised about a 12-hour delay in medical review and escalation after malaena was noted, and that anti-coagulation therapy was not withheld. The late disclosure of the 72-hour care review also impacted inquest preparation for the family and coroner.
Response (Whittington Health NHS Trust): • The ward manager provided feedback to the nurse regarding the escalation of melaena. • Direct feedback and learning were provided to the reviewing doctor concerning the assessment of gastrointestinal … (AI summary)
Responded
Mark Beresford
Concerns: The coroner raised concerns about the prison's risk assessments and an inexperienced officer setting ACCT observation levels without required supervisory consultation after significant risk incidents. Additionally, the Head of Operations provided incorrect evidence regarding policy and cell bell cover.
Response (HM Prison and Probation Service): • HMP Ranby provides regular training and guidance to staff on the ACCT process. • Guidance has been issued to staff to improve understanding of ACCT, including the requirement for … (AI summary)
Responded
Select committee recommendations(13)
#7 —
Recommendation: We did not find evidence of deliberate efforts to obstruct the prosecution. The sequence of events nevertheless raises some substantial questions of whether the Government officials and counsel working on the DNSA’s witness statements could have found an alternative formulation …
Response attribution not verified
#5 —
Recommendation: It is regrettable that the prosecution hinged on the testimony of a Government witness who would not state directly that China posed an active threat to national security at the material time. We acknowledge 48 however the arguments from the …
Response attribution not verified
#3 —
Recommendation: The witness statements provided by DNSA were however clear that China posed a range of threats to the United Kingdom’s national security. In our view it is plain that, taken together, these amounted to a more general active threat to …
Response attribution not verified
#2 —
Recommendation: The Deputy National Security Adviser (DNSA) would not describe China as posing an “active threat” to national security at the relevant time. We acknowledge the position from the Crown Prosecution Service that it would undermine their case that China represented …
Response attribution not verified
#2 —
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 …
Response attribution not verified
#11 —
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.
Response attribution not verified
#11 —
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 …
Response attribution not verified
#22 —
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 …
Response attribution not verified
#9 —
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 …
Response attribution not verified
#8 —
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 …
Response attribution not verified
#22 —
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 …
Response attribution not verified
#8 —
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 …
Response attribution not verified
#5 —
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 attribution not verified
PPO death in custody recommendations(4)
The Governor
The Governor should ensure that information published on social media about a prisoner’s death is appropriate, accurate and that the nature of the death is not revealed until confirmed by HM Coroner.
The Governor of The Mount
The Governor of The Mount should ensure that all evidence, including electronic evidence, relevant to a death in custody is retained and made available to the PPO in line with PSI 58/2010.
The Governor
The Governor should ensure that prison staff provide all relevant information requested by the Prison and Probation Ombudsman’s office, in line with PSI 58/2010.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that the evidence is made available to the PPO, in line with PSI 58/2010.
IMB individual recommendations(4)
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Governor / Director
Noted
Wandsworth (2024)
In the past year, the IMB was not always informed of major incidents, particularly Deaths in Custody. Can you assure us that you will put a process in place to rectify this?
Governor / Director
Lancaster Farms (2023)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody or the use of the special cell, are implemented. And that the Board receives responses to issues it raises in its weekly reports.
Governor / Director
Ford (2020)
Rehabilitation should be at the forefront of policy decisions relating to the open estate and your department’s handling of the Coronavirus Job Retention Scheme (“furlough”) was deplorable. Conflicting and misleading information has almost certainly led to some men leaving the prison system disadvantaged by significant amounts of money with which to re-enter the community at a time when they needed …
Ministry of Justice
Implemented
Health investigations(4)
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 14
West Hertfordshire Hospitals NHS trust should ensure that responses to reports from the Coroner are accurate and that procedures are in place to make sure that Rule 43 reports are identified and that information is collected and action considered within a governance process which is monitored by the trust board.
east_of_england
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 32
NHS England and NHS Improvement should develop guidance for Trusts and NHS organisations more widely in relation to the following aspects of recommendation 5 (R26) above: • Statements to Coroners written in relation to whole episodes of care involving a team or a Trust service should be subject to validation …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Ms A — Rec 11
The Trust should review the Bracton Centres communication with the MoJ, as correspondence to the MoJ did not fully reflect Ms A’s behaviour and presentation.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Assurance Review: Trust recommendations — Rec 26
Mortality review (Link to R10 and R15) • Any post-operative death should be subject to rigorous and contemporaneous case review and monitored at Trust level. This would also help support accurate reports to the Coroner if required to be written some months post-death. • Death summaries and sudden death reports …
north_west
Article 2 learning points(3)
— LP 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
The Governor
Accepted
— LP 18
The list of documents to be retained as set out in PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults where an independent investigation will be necessary should mirror that in PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from …
HMPPS
Accepted
— LP 17
All relevant documentation relating to a prisoner following an incident that may result in an investigation under Article 2 should be promptly secured.
HMPPS
Accepted
Independent reviews(2)
Morecambe Bay Investigation — Rec 30
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 not to coach staff or provide 'model answers', the need …
Health & Social Care
Jones: Patronising Disposition Review — Rec 15
It is difficult to overstate the impact of the failures of pathology at the first inquest. The impact is deeply personal for those families who feel they will now never know how their loved one died, but it also has a wider resonance – leading as it did to the …
Policing & Security
PHSO casework decisions(28)
P-003667 — South Tyneside and Sunderland NHS Foundation Trust
Mrs O complained the Trust failed to inform her husband his cancer was untreatable and provided inappropriate post-operative nursing and discharge, denying them preparation time.
NHS in England
Jul 2025
P-004785 — A practice in the Torbay area
Mr A complained the practice incorrectly completed his father’s death certificate, didn't provide an amended certificate without cost, and mishandled his complaint.
NHS in England
Feb 2026
P-001720 — A practice in the Wirral area
Mr O complained his GP practice failed to correctly interpret blood pressure and cholesterol results from 2016-2018, leading to his chronic heart disease diagnosis.
NHS in England
Jan 2023
P-003908 — Epsom and St Helier University Hospitals NHS Trust
Dr U complained a Trust nurse gave misleading information about her son, failed to update records with dietician letters, and sent false information to his school.
NHS in England
Jul 2023
P-002626 — A practice in the North Yorkshire area
Mrs N complained a GP practice shared inaccurate information with a mental health tribunal in 2019, causing an incorrect decision and significant distress.
NHS in England
May 2024
P-004230 — University Hospitals Birmingham NHS Foundation Trust
Mrs H complained her right lung was damaged during a biopsy in 2016, causing worsened breathing difficulties. She also alleged inaccurate information about who performed the surgery.
NHS in England
Nov 2025
P-004371 — Lewisham and Greenwich NHS Trust
Mrs E complained about delays in her father's care and discharge, an unfair COVID-19 test request, and false claims about medication delivery, causing distress.
NHS in England
Nov 2025
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complained his father was sexually assaulted by another patient, alleging the Trust knew of the risk but failed to safeguard and later provided false information in its response.
NHS in England
Jan 2026
P-001218 — Children and Family Court Advisory and Support Service
Mr A complained Cafcass incorrectly told a court he had been convicted of assaulting his ex-wife, which he denies. This caused him significant stress, sadness, and depression.
UK Government
Not Upheld
Nov 2021
P-002047 — Northumbria Healthcare NHS Foundation Trust
The Trust did not accurately autopsy her father's body, causing anxiety about organ mix-up and exacerbating her grief.
NHS in England
Jun 2023
P-002311 — Mid Yorkshire Teaching NHS Trust
Mrs I complained the Trust wrongly diagnosed her husband with lung cancer and discharged him while confused and unable to walk or talk, causing her distress.
NHS in England
Nov 2023
P-003153 — A practice in the Oadby and Wigston area
Mr A complained the GP Practice failed to visit his brother after hospital discharge, leading to his death, and recorded incorrect information on the death certificate, causing distress.
NHS in England
Not Upheld
Nov 2024
P-003275 — North East Ambulance Service NHS Foundation Trust
Mrs G complained the Trust took too long to get her husband into an ambulance because the first ambulance lacked appropriate equipment, believing faster transport might have saved his life.
NHS in England
Jan 2025
P-003443 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs V complained the Trust gave her husband inappropriate medication, failed to drain his kidneys, provided confusing diagnoses, and improperly preserved his body, causing distress.
NHS in England
Mar 2025
P-003742 — Portsmouth Hospitals University NHS Trust
Ms M complained the Trust failed to diagnose her father's cancer in a timely manner, incorrectly advised he was cancer-free, delayed disclosing his diagnosis, and failed to promptly replace a stent.
NHS in England
Not Upheld
Aug 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complained the Trust failed to diagnose her father after surgery, poorly managed sepsis, lacked awareness of blood clots, and did not refer his death to the coroner, causing his death.
NHS in England
Sep 2025
P-004132 — Oxford University Hospitals NHS Foundation Trust
Dr A complained her mother choked while being fed by a nurse, leading to aspiration pneumonia and death. She also alleged no incident report was filed and the Trust's review was inadequate.
NHS in England
Upheld
Oct 2025
P-004707 — A practice in the Chesterfield area
Mr L complained the Practice provided unclear information, a doctor misled him about a referral and misrepresented old records, and the Practice lied in its complaint response.
NHS in England
Jan 2026
P-002342 — Hampshire Hospitals NHS Foundation Trust
Mr T complained the Trust incorrectly diagnosed his wife with a ruptured breast implant, recommending urgent surgery not provided, leading to unnecessary private surgery and his wife's distress.
NHS in England
Upheld
Sep 2023
P-002497 — Barts Health NHS Trust
Mr L complained he was misdiagnosed with an STI in February 2022, treated unnecessarily, causing distress and relationship issues. He also complained about the Trust's delayed complaint handling.
NHS in England
Mar 2024
P-002553 — Stockport NHS Foundation Trust
Nurses failed to clean his wound after surgery, leading to severe infection, forcibly removed his surgical drain, and wrongly told him he had cancer.
NHS in England
Apr 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complained clinicians failed to act on her mother’s high risk of falls in December 2022, leading to serious injuries and her death. She also alleged documentation was falsified.
NHS in England
Sep 2024
P-003069 — The Princess Alexandra Hospital NHS Trust
Mrs W complained about a delayed CT scan, missed AF diagnosis, lack of family contact when her father deteriorated, being misled, and incorrect causes of death on his death certificate.
NHS in England
Oct 2024
P-003062 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complained about her uncle's inappropriate discharge, incorrect falls risk assessment, lack of a Zimmer frame, and inaccurate information about his mobility, leading to readmission.
NHS in England
Upheld
Oct 2024
P-003165 — Guy's and St Thomas' NHS Foundation Trust
Mr L complained a physiotherapist failed to use two-person assistance to move his mother and lied about a fall, which he believed led to her becoming bedbound and developing pressure sores.
NHS in England
Nov 2024
P-004147 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss U complained about delayed stroke treatment, inconsistent information, early induced coma exit, and conflicting accounts, believing these contributed to her father's death.
NHS in England
Oct 2025
P-002056 — A dental practice in the Croydon area
Mrs O complained a dental practice provided misleading information before treatment, resulting in tooth loss, ongoing discomfort, and psychological damage.
NHS in England
Jun 2023
P-003894 — The Royal Wolverhampton NHS Trust
Mr R complained about inaccurate cancer recording, delayed diagnosis and poor care for his late wife, poor complaint handling, and failure to offer genetic testing for his family.
NHS in England
Jun 2023
LGO / SPSO decisions(6)
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
CJINI inspection reports(4)
Review of the State Pathologist’s Department in Northern Ireland
State Pathologist's Department, Forensic Services
Jun 2005
Report on the Inspection of Forensic Science Northern Ireland
Forensic Science Northern Ireland, Forensic Services
Dec 2005
State Pathologist’s Department – A Follow-up Review
State Pathologist's Department, Forensic Services
Oct 2006
Report published on the State Pathologist’s Department
State Pathologist's Department, Forensic Services
Aug 2014