Caroline Adeyelu

Dear Madam

Inquest touching upon the death of Caroline Adeyelu Thank you for your report dated 5 March 2026 in relation to the death of Caroline Adeyelu. Firstly, I sincerely apologise for any continued distress this has caused to the family of Caroline Adeyelu. NELFT takes this matter very seriously and I want to assure you that we are implementing the necessary changes based on the review of (son of Caroline Adeyelu) care to prevent a recurrence of the family’s experience.

The Regulation 28 Report to Prevent Future Deaths outlined two areas for further action: firstly, the substantive review of safeguarding training in relation to adult child to parent domestic abuse and secondly the process for direct and immediate operational liaison between the Trust and the Metropolitan Police Service in addressing the risk of violence compounded by mental ill health. This letter outlines the actions we have taken.

In relation to the training that our staff are required to complete for safeguarding we are implementing the following:

• We have completed the review of the Trust’s Safeguarding Level 3 face-to-face training and have included dedicated content within the existing domestic abuse section to address adult child to parent abuse (ACPA). This has been enhanced with the inclusion of new case study activity to increase staff learning and application in clinical practice. Attendance at Safeguarding Level 3 training is a

mandatory training requirement and therefore this will include all staff across a rolling period. This review has been completed and this training is being delivered within the organisation.

• Our Safeguarding lead has also contacted Health Education England to explore the inclusion of ACPA training within the national Safeguarding Levels 1 and 2 e-learning packages. These packages are available to all NHS bodies and therefore we await the outcome of these discussions and will be sharing the Regulation 28 report as part of the supporting evidence for inclusion.

• We are updating a separate Domestic Abuse e-learning training package which is listed as ‘essential to role’ training and is therefore in addition to the above mandatory training requirements. This update be completed by 30th April 2026.

• A 7-minute briefing on ACPA is now in development and will be incorporated into our Safeguarding Assurance reports for dissemination across all services and teams within the trust. This will support the dissemination of learning for all staff and will commence in May 2026.

• The Trust safeguarding lead will be including ACPA in the regular Domestic Abuse awareness sessions at both the ‘All-staff webinar’ and the Trust Safeguarding Practitioners’ event. This will take place by the end of June 2026.

• The Safeguarding Adult (SGA) policy is currently under review, and will now specifically include ACPA. In addition, the Trust Safeguarding lead is adding an ACPA addendum to the Domestic Abuse Policy. These changes to policy will be ratified by the end of May 2026. In relation to the direct and immediate operational liaison between the Trust and the Metropolitan Police Service the Chief Executive Officers of both North East London NHS Foundation Trust (NELFT) and East London NHS Foundation Trust (ELFT) have written directly to Sir Mark Rowley of the Metropolitan Police Service to reset and strengthen our collective approach. Whilst we continue to engage at a Borough Command level (with the most recent collective review taking place on 14th April), we have advised that we would welcome the opportunity to work on and agree:

• more effective and direct operational liaison between mental health services and the Metropolitan Police Service
• clearer shared expectations around risk escalation and safeguarding responses
• practical steps to support frontline staff across our organisations to work confidently and collaboratively in high-risk situations.
• how we can deliver training to front line police officers by mental health professionals

A meeting to review these issues in more detail has now been arranged to take place on Friday 1st May in order to agree the most effective way to supplement arrangements in place in North East London in this area.

Chair: Eileen Taylor Chief Executive: Paul Calaminus

I hope this is helpful in responding to the concerns raised. We will continue to work in these areas to improve our response to patients under our care and to do so in effective partnership with police and colleagues from other agencies.

Dear Madam,

RE: RESPONSE TO REGULATION 28

1. I am writing to provide a response to the concerns that you raised after the conclusion of the inquest touching the death of Ms Caroline Adeyelu.

2. The Trust gratefully notes your observations, and wishes to update you on its work in the following areas:

 Concern 1 – “The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of homebased risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.”

 Concern 2 – “The inquest heard concerns from multiple witnesses about the lack of effective communication systems in place between the mental health services and the Metropolitan Police Service, in circumstances where there are dual forensic and mental health concerns. Whilst there are clearly higher-level meetings that take place between the trusts and the MPS, these do not address the needs of psychiatrists and police officers working on the frontline who are having to address pressing risk issues – both in assessing and in managing risk. Such liaison needs to be prompt – in some cases immediate. Liaison may be from the MPS to the Trust (for example in risk assessing missing persons) or from the trust to the police (for both risk assessment and how to best manage risk). The inquest heard that communication both ways was challenging. The challenges have increased since the introduction of the Right Care, Right Person policy has been introduced. In some cases, communication was not attempted at all, because of the assumption that the appropriate professional was unlikely to be reached. Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.”

3. The Trust has undertaken a great deal of reflection and learning since Ms Adeyelu’s very sad death on 30 October 2022. I outline this work below to provide you and Ms Adeyelu’s family with reassurance that the Trust has taken this matter very seriously.

Concern 1: The extent of training at the Trust on this subject is insufficient to address the widespread concerns encountered in this matter.

4. Through-out the inquest process, the Trust provided you with evidence as to the training and systems it has put into place to prevent intergenerational domestic abuse. This included:

 The Trust’s level three safeguarding training now highlights domestic abuse from children (with or without mental health needs) to parents.

 The learning identified from the Trust’s Individual Management Review (IMR) provided for the Domestic Homicide Review into Ms Adeyelu’s death was considered in Tower Hamlets quarterly safeguarding supervision on 4 July 2024 and 5 June 2025.

 Domestic abuse and Violence Against Women and Girls (VAWG) Champions have been trained across all clinical service areas in Tower Hamlets to support clinicians.

 An intergenerational domestic abuse training session was held virtually at the Trust’s annual safeguarding conference (delivered by the charity Hourglass).

 Tower Hamlet’s admissions checklist was updated on 23 December 2025 to include intergenerational safeguarding concerns.

 The Trust strengthened its guidance and approach to routine enquiry into domestic abuse.

5. Upon receiving your Regulation 28 report, the Trust further strengthened its Level 3 Safeguarding Training (which is mandatory for all patient facing clinical staff). It now explicitly references evidence from the Femicide Census and the Domestic Homicides and Suspected Victim Suicides 2020–2025 Report (published April 2026 ) on the prevalence of mothers being killed by their sons and the frequent presence of mental ill health as an antecedent risk factor in the section on children-adult abuse.

6. The training is designed to challenge mental health professional’s perceptions that family is always inherently protective and reinforces parental vulnerability when caring for adult children with mental health support needs. The training highlights that caring roles should not be assumed but actively explored and verified. It places emphasis on ensuring that mental health professionals explicitly consider risk to family members as well as partners and ex-partners and assess whether these risks meet the threshold for domestic abuse. It also stresses that risks should not be viewed solely through a mental health lens: abuse must be recognised as abuse, regardless of whether mental ill health is present, and should be responded to through appropriate safeguarding and domestic abuse pathways.

Concern 2 - Processes for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.

7. The Trust also provided evidence at the inquest as to the improved processes that have been put into place between the police and the Trust since Ms. Adeyelu’s death. This included:

 Training of all staff in Tower Hamlets in relation to expectations about contacting the police after Right Care, Right Person commenced.

 Updating in-patient ward processes to ensure that risk assessments are completed prior to periods of Section 17 leave.

 Creation of a monthly liaison meeting between the local police and Tower Hamlets directorate to discuss concerns arising across in-patient and community services.

 Updated communication sent to all clinicians highlighting how to contact police and the agreed processes.

8. Upon receiving your Regulation 28 report the Trust has reflected on your concerns and agrees that it must continue to improve its communication with the police. This is especially the case as the police force’s dedicated mental health liaison workers have just been disbanded. This, alongside pre-existing limitations in information sharing between the Trust and the police and operational challenges associated with Right Care, Right Person will make joint working more difficult. To this end, on 1 May 2026, the Trust’s Chief Executive Officer, Deputy Chief Executive Officer and Chief Medical Officer will be meeting with the MPS Lead Responsible Officer for Mental Health, other senior MPS officers and North East London NHS Foundation Trust to discuss how to best manage these changes and strengthen integrating working in future. The following items will be considered:

 More effective and direct operational liaison between mental health services and the Metropolitan Police Service.

 Clearer shared expectations around risk escalation and safeguarding responses.

 Practical steps to support frontline staff across our organisations to work confidently and collaboratively in high-risk situations.

 How we can deliver training to front line police officers by mental health professionals.

Conclusion

9. I hope this response provides sufficient reassurances to you and to the family of Ms Adeyelu about the learning that has taken place at the Trust since her sad death.

10. I would like to offer my sincere and heart-felt condolences to her family at this difficult time.

Dear Miss Persaud Deputy Assistant Commissioner Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A 2JL Friday 8" May 2026 Prevention of Future Deaths - Ms. Caroline Adeyelu We acknowledge receipt of your Regulation 28 report dated 5" March 2026 concerning the inquest into the death of Ms Caroline Adeyelu. We extend our sincere condolences to the family and all those affected by this tragic event. The Metropolitan Police Service (MPS) has acknowledged and reviewed the matters of concern raised in your Regulation 28 Report and responds as follows: Matter of Concern 2 Summary "Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health". MPS Response The Metropolitan Police Service acknowledges the Coroner's concerns regarding the lack of effective communication systems between the MPS and NHS mental health services where individuals present with both forensic and mental health needs. We recognise that although strategic-level partnership meetings take place between the MPS and Mental Health Trusts, these do not always translate into the prompt, operational liaison required by fronti ine officers and clinicians who are managing urgent and complex risk. The inquest highlighted several difficulties, including challenges establishing timely two-way communication, uncertainty around who to contact for clinical advice, and reduced clarity following the introduction of the Right Care, Right Person (RCRP) Policy'. The inquest heard evidence that on some occasions communication was not attempted due to assumptions about the availability of the relevant professional. We note the Coroner's recommendation for ' RCRP approach assesses if the police are the most appropriate service to respond.

establishing a more reliable system of direct and immediate liaison in situations where an individual presents both mental ill health and a risk of violence. In response, the MPS has already undertaken a comprehensive review of existing information-sharing pathways with Mental Health Trusts. This work identified inconsistencies across London, including where current arrangements rely on informal, individual-based contact rather than clear, structured systems. The review also highlighted the absence of designated contact points that can be accessed reliably by fronti ine officers and clinical teams in urgent circumstances. These gaps create the potential for delays, missed opportunities for intervention, and uncertainty for those involved in managing shared risks. As part of strengthening partnership working, the MPS has met directly with both North East London NHS Foundation Trust (NEFLT) and East London NHS Foundation Trust (ELFT) to discuss improved operational information flow between policing and mental health services. These discussions have focused on how frontline officers and clinicians can access timely, proportionate information, how points of contact can be clarified at an operational level and how escalation routes can be strengthened when immediate clinical or police input is required. This engagement has supported a shared understanding of respective roles under RCRP and the importance of predictable, reliable communication arrangements when managing individuals who present with mental ill health and associated risk. To address these issues, the MPS is developing a new direct liaison protocol to support immediate frontline communication between officers and Mental Health Trust clinicians when an individual presents a combination of meritai ill health and risk of violence. The protocol is being developed with local partnership governance structures and aims to clearly define who should be contacted, ensure round-the-clock accessibility to the appropriate advice, ano set out the respective responsibilities of both. police and clinical services under RCRP. This work also includes reinforcing existing routes available to officers, such as the use of the mental health clinical advice line, which provides timely clinical guidance where appropriate and helps support informed decision making in real time situations. The protocol is being aligned with the relevant data protection and safeguarding frameworks to allow information to be shared safely and lawfully. Importantly, this work is intended to establish consistent operational expectations across all London boroughs so that frontline practitioners experience predictable and reliable routes of communication, regardless of location. It is anticipated that this work will be completed by the beginning of next year. In the interim, on 2nd April 2026, communication was issued to all Borough Commanders reminding them of the requirement to ensure that officers utilise the Mental Health Clinical Advice Line whenever they engage with or are required to make decisions concerning a person known or believed to be experiencing mental ill health. This information has also been published on the Mental Health page of the Public Protection SharePoint. The MPS is continuing to work closely with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to refine and strengthen these arrangements. This includes agreeing escalation routes when urgent clinical input is needed, clarifying points of contact, and aligning operational processes with both clinical practice and policing risk assessment frameworks. This collaborative approach reflects our shared commitment to improving how risk is assessed and managed in real time.

The MPS remains committed to strengthening frontline information sharing and communication with Mental Health Trusts. We fully recognise the need for rapid, accessible, and dependable liaison in circumstances where a person's mental health presentation and risk of violence intersect. The actions outlined above are intended to ensure that officers and clinicians have the timely access to advice and information they need to safeguard individuals and the wider public. We are grateful for the Coroner's observations and for the opportunity to improve the systems that support officers and clinicians responding to people in crisis. The MPS will continue working with NHS partners to prevent future deaths and ensure vulnerable individuals receive coordinated, timely and appropriate care. Please do not hesitate to contact me should you require further information.