“That CNWL failed in its duty of candour in relation to provision of evidence in this case”
Dated 16 Feb 2024, from the coroner for Inner 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
Deadline passedReplies were due by 12 Apr 2024. 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 dated16 Feb 2024
- Deadline12 Apr 2024
- Published on judiciary.uk22 Feb 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation Trust | 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. |
| Metropolitan Police Service | Response publishedPublished on judiciary.uk in February 2024. |
| NHS England | Response publishedPublished on judiciary.uk in February 2024. |
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
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case. 2. That the evidence given by the SPA witnesses was at times not credible. 3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth. 4. That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person’s date of birth. 5. That CNWL were and may still be unaware that CNWL staff operate outside policy. 6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case. 7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services. 8. That other areas in England could learn from how section 136 suite access has been restructured in London. 9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate. 10. That there are continued shortages in psychiatric care provision.
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, 2024-0087
- 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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