“That neither the initial caller, nor a passer-by who continued the call with the…”
Dated 25 Jun 2019, from the coroner for Inner South 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 23 Aug 2019, after the 56 days for replies had ended (20 Aug 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated25 Jun 2019
- Deadline20 Aug 2019
- Published on judiciary.uk23 Aug 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| 999 Liaison Committee | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Department of Culture Media and Sport | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| London Ambulance Service NHS TrustNamed in the report as “London Ambulance Service” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently invoive other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or . 2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference. It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible, and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.
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, 2019-0210
- 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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