This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 7th September 2023, an inquest into the death of Edward Muwanga was opened who died on 7th August 2023 aged 36 years. The inquest was held and concluded with a jury between 19th – 27th January 2026 and 3-4 March 2026
Findings of the Jury: The medical cause of death was 1(a) Multiple trauma
How, when and where
On August 7th 2023, Edward Muwanga entered Queensway London Underground Station. He descended on to the trackway, where he was struck by a train, which resulted in his death. Based on the evidence provided, we find that the following matters were probably causative of his death:
a) The actions of Eddie when entering the track; and
b) There was a delay by central line controllers in notifying the driver to slow down and/or stop the train.
There are a number of failings or omissions that we wish to record:
1) The Care Co-ordinator was made aware that a warrant to section Eddie was granted on 2nd August 2023. This information was not provided to Eddie's assisted living facility.
2) As a consequence, when Police and Ambulance crews attended Eddie's assisted living facility on 6th August 2023, (following reports of him walking into oncoming traffic), they were not made aware of the warrant having been granted. Similarly, the 111 NHS doctor who discharged Eddie from the Ambulance's care made their decision to do so without this crucial information.
3) The LAS attendee provided limited information and details regarding Eddie's condition to the NHS 111 doctor. Notably, the record of their call indicates that the 111 NHS doctor inferred from his comments that Eddie would be watched closely by employees in his assisted living facility in the hours that would follow. This led to them agreeing to the discharge.
4) The LAS NHS Trust made a series of admissions about the NHS 111 doctor as follows:
a) There was a failure to communicate with Eddie directly on the 6th August 2023 during the course of his assessment; and
b) There was a failure to communicate with Eddie's community mental health team.
These acknowledged shortcomings did not affect the outcome.
5) The Police's visit to Eddie's assisted living facility was cursory in nature. They left after spending no more than ten minutes discussing his prior actions, his condition and the plans for his oncoming care and wellbeing. The haste with which they departed - having failed to take reasonable steps to check the status of the warrant - is a noteworthy omission, and indicative of a cavalier attitude to someone in a mental health crisis. A more detailed, measured and thoughtful assessment of Eddie's situation was warranted.
6) The Police officers who attended Eddie on 6th August 2023 did not properly understand their powers under Section 136 MHA 1983.
Conclusion Accidental Death: Caused by Eddie's entry on to the trackway. We do not believe he intended to die.
Circumstances of the death
Edward Muwanga (Eddie) had a diagnosis of paranoid schizophrenia since 2010 which encompassed auditory hallucinations including commands from God. He suffered from times when he determined not to take his prescribed medication which led to a deterioration in his self care and neglect of his hygiene. He was being treated by the community mental health team from South London and Maudsley NHS Trust. In July matters had deteriorated to the point his treating psychiatric team determined he should be assessed at a hospital. Eddie refused to go and so steps were taken to obtain a warrant under section 135 MHA 1980 to take him under compulsion. A warrant was granted on 2nd August 2023 but was not executed. Eddie’s accommodation at 2 Verdant Lane were aware of the application to obtain the warrant but on 6th August were not aware it had been granted. Eddie was not detained at 2 Verdant Lane which was supported living accommodation and not locked or restricted in any way. On 6th August 2023 Eddie left his accommodation and entered the road outside. Staff were concerned for him and dialled 999. Police attended on the 999 call but Eddie had returned to the shared lounge at his accommodation. Police did not speak to him. Officers believed wrongly that they could not use their powers under section 136 MHA 1980 because Eddie was in the lounge at his home, even though this was a shared lounge with other residents. The London Ambulance Service were also spoken to by both police and staff at the accommodation. Police left without speaking to or assessing Eddie as they felt matters were better addressed by the ambulance team. They also made no enquiries as to the existence of the section 135 MHA 1980 warrant, when information could have been obtained that addressed that. The ambulance crew assessed Eddie and called an NHS 111 doctor for approval to leave Eddie on site as they considered it was safe to do so. The NHS 111 doctor agreed he could remain on site, but had not accessed all of his available medical notes. At 2200 on 6th August 2023 Eddie left his accommodation unnoticed, and eventually arrived naked at Queensway underground station at about 0655. He entered the station, descended to the platform where he climbed down onto the running tracks as a train was entering the station. He was struck despite the train driver applying emergency braking and suffered multiple injuries from which he died at the scene. The jury found that there was a delay by central line controllers in alerting the driver of the train to Eddie’s presence which probably contributed to the death. In addition the jury found and recorded other failings and omissions set out above.
Coroner’s concerns
(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 (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. (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.
In relation points (1) and (2) I believe the Commissioner of Police for the Metropolis, and the College of Policing are responsible for how officers are trained and educated, and which are the relevant practices and processes for officers to adopt when dealing with persons in mental health crisis in the community as part of their core policing duties. The Commissioner is also responsible for ensuring that processes exist whereby officers can locate and identify relevant information to the exercise of the duties such as the existence of the section 135 warrant in this matter.
In relation to point 3 I believe NHS England, London Ambulance Service NHS Trust, South London and Maudsley NHS Foundation Trust and OneLondon Board all have a part to play in the delivery of integrated and accessible care records and as such can take action to prevent future deaths.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised5
Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Failure to make a detailed and measured assessment of a person’s situation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.37
Action
Use the Delivery Oversight Group to manage and track implementation of the information-sharing improvement plan.
Stated byOneLondon BoardStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Ensure full London coverage of the Thalamos electronic Mental Health Act system.
Stated byOneLondon BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Build and link mental-health care and crisis plans in the Universal Care Plan and Mental Health Trust electronic records.
Stated byOneLondon BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Share electronic Mental Health Act data, including alerts and relevant history, in the London Care Record.
Stated byOneLondon BoardStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Introduce the Thalamos electronic Mental Health Act system across London.
Stated byOneLondon BoardStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Review presentation options with the London Care Record supplier to make important information clearer.
Stated byOneLondon BoardStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Conduct the London Care Record procurement exercise to determine future systems.
Stated byOneLondon BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Take actions to address gaps in mental-health information sharing.
Stated byOneLondon BoardStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Design a standard care and crisis plan for use in the Universal Care Plan.
Stated byOneLondon BoardStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Include pan-London mental-health information sharing and clear clinical alerts as essential procurement criteria.
Stated byOneLondon BoardStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Review Authorised Professional Practice guidance and consider the report’s concerns in resulting amendments.
Stated byCollege of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Strengthen policy and operational processes for identifying, executing, and managing requests for assistance at section 135 warrants.
Stated byMetropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Deliver comprehensive training on Mental Health Act sections 135 and 136, including communal-area powers, warrants, and safeguarding.
Stated byMetropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Issue operational notices clarifying the lawful use of section 136 powers in communal areas.
Stated byMetropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Embed enhanced supervisory oversight and escalation processes within control-room decision-making.
Stated byMetropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Record section 135 warrants on police intelligence systems accessible to all officers.
Stated byMetropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Continue reinforcing Mental Health Act and Right Care, Right Person training through regular audit and quality assurance.
Stated byMetropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Adopt and operate London Care Record sharing to provide authorised clinicians with near-real-time access to relevant mental health information.
Continue working with system partners to strengthen information sharing, improve shared-record consistency and usability, and support coordinated care.
Set a national interoperability initiative and commit investment to enable authorised professionals to access reliable records across England.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Secure funding for South London and Maudsley NHS Foundation Trust to develop a business case for replacing its non-compliant EPR.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Develop and lead the Frontline Digitisation Programme, providing EPR adoption support, implementation guidance and safety oversight.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Secure funding for London Ambulance Service NHS Trust to add linked dispatch, interoperability, emergency-department record linkage and EPR optimisation functionality.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Enable visibility of Computer Aided Dispatch information within electronic patient care records to support clinical decision-making.
Stated byLondon Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Consider interoperability enhancements between the London Care Record and National Record Locator through OneLondon procurement and strategic planning.
Stated byLondon Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Promote Universal Care Plans to partner organisations for shared care planning.
Stated byLondon Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Continue LAS participation in the NHS England Single Patient Record Programme Clinical Reference Group.
Stated byLondon Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Continue collaborating with regional, local and national partners to improve shared-care planning and cross-organisation information access.
Stated byLondon Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Maintain implemented clinical-system flags and visual prompts alerting clinicians to shared care plans and key documents.
Stated byLondon Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Collaborate with the Universal Care Plan team to develop mental-health and catheter-care personalised care-planning use cases.
Stated byLondon Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Embed updated shared-record access and safety-information guidance in induction, mandatory training and clinical communications.
Stated byLondon Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Embed mental health assessment guidance in the electronic patient care record tool to prompt care-record review.
Stated byLondon Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Deliver expanded mental-health training through induction, conferences, rolling case-based sessions, targeted sessions and accessible resources.
Stated byLondon Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Integrate electronic patient care records with the London Care Record to reduce access time and streamline navigation.
Stated byLondon Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Action
Develop further visibility, access and flagging for National Care Record Service documents and alerts within clinical systems.
Stated byLondon Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.11
Position
Further sharing of s136 information into the London Care Record depends on Mental Health Trusts and police organisations agreeing to share it.
Stated byOneLondon BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Technical constraints currently limit the ability to change how information is presented in the London Care Record.
Stated byOneLondon BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Work to address Mental Health Trust data-sharing gaps is constrained because funding has not yet been confirmed.
Stated byOneLondon BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Metropolitan Police Service is responsible for addressing operational elements and decision-making processes and is providing the substantive response.
Stated byCollege of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mental health crises should be led by health services, with police involvement limited to lawful powers, crime, or immediate serious harm.
Stated byMetropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England states that interoperability is configured and managed locally through provider organisations and technology suppliers, with regional teams considering wider catchment areas.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local Integrated Care Boards are responsible for delivering shared care records according to local needs, systems and plans.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Further enquiries about NHS 111 and ambulance access to Summary Care Records through NCRS should be directed to the London Ambulance Service.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local shared care record organisations and NHS Trusts must agree additional information sharing and negotiate local data-sharing protocols.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for electronic-record information sharing and management rests with each organisation through established digital governance arrangements.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Additional London Care Record flagging is not considered beneficial because most attended patients already have information published there.
Stated byLondon Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7
1
Continue joint working with partner organisations to improve mental-health and patient-safety information sharing.
Stated byOneLondon BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
2
Introduce a OneLondon Delivery Oversight Group.
Stated byOneLondon BoardStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
3
Support police forces implementing Right Care Right Person through the implementation toolkit and ongoing collaboration with the National Police Chiefs’ Council.
Stated byCollege of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
4
Work closely with NHS partners to improve outcomes and ensure people receive appropriate care from the right professional.
Stated byMetropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
5
Engage with partner organisations through internal and multi-agency discussions to identify learning and improve information sharing for safe Mental Health Act decision-making.
Discuss all received Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1
1
One London Board is providing the regional response and actions directly to the Coroner, so further details are not provided.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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