Source · Prevention of Future Deaths
Alexia Walenkaki
Ref: 2018-0193
Date: 22 Jun 2018
Coroner: ME Hassell
Area: London Inner (North)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted equipment failure due to inappropriate materials and a lack of accountability for annual inspections, particularly regarding unclear staff handovers. Concerns remain about potential recurrence of these organizational issues.
Date
22 Jun 2018
56-day deadline
4 Sep 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner noted equipment failure due to inappropriate materials and a lack of accountability for annual inspections, particularly regarding unclear staff handovers. Concerns remain about potential recurrence of these organizational issues.
View full coroner's concerns
The jury identified two causative factors in the equipment failure that resulted in Alexia’s death:
- inadvertent use of inappropriate wood;
- organisational failure and lack of accountability for annual inspections.
When one person was suspended and another went on maternity leave, there was no clear handover of responsibility for annual inspections. I fear that a lack clarity and continuity in terms of role demarcation and management structure may persist, particularly when staff move on.
Whilst I heard that there have been changes at Tower Hamlets since Alexia’s death, I am concerned that there is the potential for recurrence of the organisational failure identified by the jury.
- inadvertent use of inappropriate wood;
- organisational failure and lack of accountability for annual inspections.
When one person was suspended and another went on maternity leave, there was no clear handover of responsibility for annual inspections. I fear that a lack clarity and continuity in terms of role demarcation and management structure may persist, particularly when staff move on.
Whilst I heard that there have been changes at Tower Hamlets since Alexia’s death, I am concerned that there is the potential for recurrence of the organisational failure identified by the jury.
Report sections
Investigation and inquest
On 28 July 2015, one of my assistant coroners, William Dolman, commenced an investigation into the death of Alexia Awenimi Walenkaki, aged nearly six years.
Following a lengthy police investigation, my investigation concluded at the end of the inquest on 17 May 2018. My most sincere apologies to you and to Alexia’s family that I am only now making this report a month later.
The jury made a narrative determination, a copy of which I attach.
Following a lengthy police investigation, my investigation concluded at the end of the inquest on 17 May 2018. My most sincere apologies to you and to Alexia’s family that I am only now making this report a month later.
The jury made a narrative determination, a copy of which I attach.
Circumstances of the death
Alexia fell from a rope suspended from a wooden post that collapsed when she was playing in a children’s play area of Mile End Park on the afternoon of 17 July 2015.
Her medical cause of death was: 1a traumatic head injury
Her medical cause of death was: 1a traumatic head injury
Copies sent to
Tower Hamlets Safeguarding Children Board, Alexia’s mum
Similar PFD reports
Report details
- Reference
- 2018-0193
- Date of report
- 22 June 2018
- Coroner
- ME Hassell
- Coroner area
- London Inner (North)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Tower Hamlets Borough Council