OneLondon Board

Health and care · Health-system partnership

Pin Request correction

First report 24 Apr 2026•Latest report 24 Apr 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
12

Described in responses

Concerns and recipient responses

Statements from OneLondon Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner West London

    AI-generated summary

    Edward Muwanga · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to OneLondon Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation

    Wider context from the report

    “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to OneLondon Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness of the section 135 MHA 1980 process

    Wider context from the report

    “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to OneLondon Board; that does not assign responsibility.

    PFD Monitor interpretation

    Fragmented healthcare record systems limiting the visibility and communication of important patient safety information

    Wider context from the report

    “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to OneLondon Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to locate and identify information about a section 135 MHA 1980 warrant

    Wider context from the report

    “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to OneLondon Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make a detailed and measured assessment of a person’s situation

    Wider context from the report

    “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use the Delivery Oversight Group to manage and track implementation of the information-sharing improvement plan.

    Verbatim wording from the response

    “We have introduced a new Delivery Oversight Group for OneLondon, and this will be asked to manage the oversight and track implementation of our plan to further improve our information sharing within our three major pan London systems (eMHA, London Care Record and Universal Care Plan as from June 2026). Through this, OneLondon will continue to seek to improve information sharing to support safer Mental Health care for Londoners.”

    Source location

    Response from OneLondon Board
    Page 7 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure full London coverage of the Thalamos electronic Mental Health Act system.

    Verbatim wording from the response

    “Currently we are still in the process of ensuring full coverage. However, the system is live in most Mental Health Trusts and available to their partners (Local Authorities etc). The eMHA by Thalamos system is live in the following 5 Mental Health Trusts in London:”

    Source location

    Response from OneLondon Board
    Page 4 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Build and link mental-health care and crisis plans in the Universal Care Plan and Mental Health Trust electronic records.

    Verbatim wording from the response

    “At the time of Edward Muwanga’s death, there was no Universal Care Plan (UCP) form because UCP was not being used to support mental health care. That is now changing and work is currently underway to build mental health care & crisis plans in the UCP – and for this to be linked to Mental Health Trust electronic patient record (EPR) systems.”

    Source location

    Response from OneLondon Board
    Page 3 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share electronic Mental Health Act data, including alerts and relevant history, in the London Care Record.

    Verbatim wording from the response

    “Data from eMHA is also now shared in the London Care Record.”

    Source location

    Response from OneLondon Board
    Page 4 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce the Thalamos electronic Mental Health Act system across London.

    Verbatim wording from the response

    “At the time of Edward Muwanga’s death, London had not yet implemented the eMHA system by Thalamos. Since the death of Edward Muwanga, a new eMHA by Thalamos system has been introduced in London. This system supports the digitisation of the Mental Health Act and aims to support more joined-up assessment,”

    Source location

    Response from OneLondon Board
    Page 3 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review presentation options with the London Care Record supplier to make important information clearer.

    Verbatim wording from the response

    “The system used for the London Care Record is provided by Oracle Health. There are currently technical constraints and limitations on the ability of the NHS to change the way that the system presents information. However, we commit this year to –”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct the London Care Record procurement exercise to determine future systems.

    Verbatim wording from the response

    “In parallel, the current contracts for the London Care Record are due to expire in the coming years – with aligned contract end dates of March 2028 agreed. This year there is a procurement exercise that has started in London which will look at what systems we will use in London.”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Take actions to address gaps in mental-health information sharing.

    Verbatim wording from the response

    “• Actions will also be taken this year to seek to address the gaps in data sharing from Mental Health Trusts. (The budget for this work is not yet confirmed as available, but there is a route through London NHSE Regional governance to address this with Trusts, and commitment in principle has been obtained).”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Design a standard care and crisis plan for use in the Universal Care Plan.

    Verbatim wording from the response

    “• In 2025 work was carried out to design a ‘care & crisis plan’ to be used in the UCP. Funding was also requested to support this work. We received funding for this work (confirmed in April 2026)”

    Source location

    Response from OneLondon Board
    Page 3 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include pan-London mental-health information sharing and clear clinical alerts as essential procurement criteria.

    Verbatim wording from the response

    “• We commit to ensuring that the procurement specification will include as essential criteria the ability to share information pan-London from all Mental Health Trusts, and a ‘user interface’ which clearly alerts clinical staff to important and relevant information about the patient they are seeing / treated.”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further sharing of s136 information into the London Care Record depends on Mental Health Trusts and police organisations agreeing to share it.

    Verbatim wording from the response

    “• Thalamos have just completed developing a s136 status with the Met Police. This is now live. (Information will therefore also be available from City Police and British Transport Police for London Region.) This is live in the Thalamos product although it is not yet shared into the London Care Record. (There are no current timescales for this – but is achievable within the next 6 months if the Mental Health Trusts and the Police Organisations agree to sharing).”

    Source location

    Response from OneLondon Board
    Page 5 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Technical constraints currently limit the ability to change how information is presented in the London Care Record.

    Verbatim wording from the response

    “The system used for the London Care Record is provided by Oracle Health. There are currently technical constraints and limitations on the ability of the NHS to change the way that the system presents information. However, we commit this year to –”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work to address Mental Health Trust data-sharing gaps is constrained because funding has not yet been confirmed.

    Verbatim wording from the response

    “• Actions will also be taken this year to seek to address the gaps in data sharing from Mental Health Trusts. (The budget for this work is not yet confirmed as available, but there is a route through London NHSE Regional governance to address this with Trusts, and commitment in principle has been obtained).”

    Source location

    Response from OneLondon Board
    Page 6 · response
    Published 19 June 2026

    Open published response
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026