“No planning for this foreseeable emergency”
Dated 8 May 2026, from the coroner for West London. Sent to 3 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
All responses publishedReplies were due by 3 Jul 2026.
Organisations 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.
- Report dated8 May 2026
- Deadline3 Jul 2026
- Published on judiciary.uk2 Jul 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Choice Support | Response publishedPublished on judiciary.uk in July 2026. |
| NHS South West London Integrated Care BoardNamed in the report as “NHS South West London ICB” | Response publishedPublished on judiciary.uk in July 2026. |
| NHS England | Response publishedPublished on judiciary.uk in July 2026. |
The coroner’s concerns
No planning for this foreseeable emergency. Inadequate staff training (to always conduct CPR if no decision to the contrary) No defibrillator on site and staff misunderstanding of the function of a defibrillator. No airway training and equipment although Registered Nursing staff have this within their competencies. I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do. This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: Interested Persons:1. The family of Jake 2.Richmond and Kingston NHS Foundation Trust 3.Choice Support It is addressed to those named in paragraph 3 I also send it to those who may be interested in it Resuscitation Council UK (Jakes GP) I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. Mrs Lydia Brown HM Senior Coroner West London
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, 2026-0251
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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