East London NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust communicated learning about medication changes and care planning to consultant psychiatrists. The guidance for the RAG rating system in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration and will be reinforced within the team. (AI summary)
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Dear Madam
RE: REGULATION 28 REPORT - Evan Amon Dandou-Dambelle
I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 29 October 2025 following the inquest touching the death of Mr Evan Amon Dandou- Dambelle.
You noted a concern as follows:
When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death.
This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration.
Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome.
However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly.
Trust Response
The Trust agrees that for all cases discussed within multidisciplinary meetings in community mental health services, including specialist services such as Early Intervention Services, any significant
proposed or enacted changes to medication should be considered and discussed as part of the decision making process related to care planning and future contact arrangements.
Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.
I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.
Conclusion
I hope this response provides sufficient reassurance to you and to the family of Mr Dandou-Dambelle.
I would like to offer my sincere and heart-felt condolences to his family at this difficult time.
RE: REGULATION 28 REPORT - Evan Amon Dandou-Dambelle
I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 29 October 2025 following the inquest touching the death of Mr Evan Amon Dandou- Dambelle.
You noted a concern as follows:
When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death.
This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration.
Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome.
However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly.
Trust Response
The Trust agrees that for all cases discussed within multidisciplinary meetings in community mental health services, including specialist services such as Early Intervention Services, any significant
proposed or enacted changes to medication should be considered and discussed as part of the decision making process related to care planning and future contact arrangements.
Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.
I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.
Conclusion
I hope this response provides sufficient reassurance to you and to the family of Mr Dandou-Dambelle.
I would like to offer my sincere and heart-felt condolences to his family at this difficult time.