“From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the…”
Dated 22 Mar 2024, 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
All responses publishedReplies were due by 17 May 2024.
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 dated22 Mar 2024
- Deadline17 May 2024
- Published on judiciary.uk25 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East London NHS Foundation TrustNamed in the report as “East London Foundation NHS Trust” | Response publishedPublished on judiciary.uk in March 2024. |
| Newham Social Care | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
- 1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways; a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further. b. When faced with the limited information withing the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report. c. The Trust failed to formally assess Mrs Ademiluyi's mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter's views which may have resulted in effective care being put in place. d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi's daughter no effort was made to offer a carer assessment to address whether she was overwhelmed by the task in hand. 2. Despite the death of Mrs Ademiluyi's occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the LocalAuthority into the failings in care by the time of the inquest almost a Vear later. lt was 2 suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client. 6 ACT¡ON SHOULD BE TAKEN ln my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
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, 2024-0161
- Added to Minute Book
- 8 Oct 2026
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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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