Chadrack Mbala MULO · Prevention of Future Deaths report

On 26 October 2016, one of my assistant coroners, William Dolman, commenced an investigation into the death of Chadrack Mbala Mulo, aged 4 years. The investigation concluded at the end of the inquest on 10 April 2017. At inquest, I made a determination as follows.

Chadrack had learning difficulties and, when his mother died unexpectedly at home on 1 or 2 October 2016, he did not know how to call for help or feed himself properly. He died a fortnight later of dehydration and starvation. He was then found within approximately 48 hours.

His medical cause of death was:
1a dehydration and acute protein-energy malnutrition
2 autism spectrum disorder (ASD)

Chadrack’s mother suffered a sudden death in epilepsy, probably on 1 or 2 October 2016. Chadrack was not seen in school after 30 September 2016.

The staff at Morningside Primary School were concerned and rang his mother on several occasions. They also visited the home twice, but could not gain access to the block of flats where Chadrack and his mother lived.

The likelihood is that Chadrack lived alone in the family home for over a fortnight after his mother’s death. He was found a couple of days after his own death, with his arms around her body. She was by then very decomposed.

1. The school had a telephone number for Chadrack’s mother, but not for any other family member or friend. Now, they insist that for every child in the school they have the telephone number of three different adults.

2. If a child unexpectedly fails to attend and no relevant adult can be contacted via phone, staff at the school do not now wait three to five days as they did then, but instead immediately send a member of staff to the family home.

They now make a distinction between an attendance issue that may warrant a penalty (not the case for Chadrack because he was under the age of five years) and a potential welfare issue.

3. If there is no answer at the family home when staff members attend, they now immediately contact the police, who in most cases are likely to force entry.

This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in place.