“2 1”
Dated 19 Sep 2025, from the coroner for East London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Dates unclearOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due.
- Report dated19 Sep 2025
- Published on judiciary.uk29 Aug 2025
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS EnglandNamed in the report as “National Medical Director, NHS England” | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| NHS North East London Integrated Care BoardNamed in the report as “Chief Nursing Officer, NHS North-East London Integrated Care Board” | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
The coroner’s concerns
– 2 1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan ('PRAP') set out the necessary steps to be considered should Kwabena fall ill. 2. During Kwabena’s final illness, those assessing him from 16 th-21st September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them. 3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved. 4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0429
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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