Coroner’s reportPrevention of future deaths · 2018-0304

Prevention of future deaths report

Dated 19 Dec 2018, from the coroner for Inner West London. Sent to 8 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

Deadline passed

Replies were due by 13 Feb 2019. A reply may have been sent and not yet published.

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.

Report dated19 Dec 2018
Deadline13 Feb 2019
Published on judiciary.uk20 Dec 2018
Today23 Oct 2026

Watch this report

We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.

Responses from each recipient

Responses from each recipient
Sent to	Response	Published response
Metropolitan Police	Response publishedPublished on judiciary.uk in December 2018. Read the response from Metropolitan Police on judiciary.uk	Read the response from Metropolitan Police on judiciary.uk
Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster	Response publishedPublished on judiciary.uk in December 2018. Read the response from Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster on judiciary.uk	Read the response from Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster on judiciary.uk
London Ambulance Service NHS TrustNamed in the report as “The London Ambulance Service”	Response publishedPublished on judiciary.uk in December 2018. Read the response from London Ambulance Service NHS Trust on judiciary.uk	Read the response from London Ambulance Service NHS Trust on judiciary.uk
Transport for London	Response publishedPublished on judiciary.uk in December 2018. Read the response from Transport for London on judiciary.uk	Read the response from Transport for London on judiciary.uk
Home Office	Response publishedPublished on judiciary.uk in December 2018. Read the response from Home Office on judiciary.uk	Read the response from Home Office on judiciary.uk
The Maritime and Coastguard Agency	Response publishedPublished on judiciary.uk in December 2018. Read the response from The Maritime and Coastguard Agency on judiciary.uk	Read the response from The Maritime and Coastguard Agency on judiciary.uk
Department for Transport	Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Feb 2019. A reply may have been sent and not yet published.	None yet
The British Vehicle Rental and Leasing Association	Response publishedPublished on judiciary.uk in December 2018. Read the response from The British Vehicle Rental and Leasing Association on judiciary.uk	Read the response from The British Vehicle Rental and Leasing Association on judiciary.uk

Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.

The coroner’s concerns

Read the coroner’s concerns in the full report on judiciary.uk.

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, 2018-0304
Added to Minute Book: 8 Oct 2026
Reuse: We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0

Ask about this report

Summaries and questions, with page references. Pro and above.