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Source · Prevention of Future Deaths

Edward Muwanga

Ref: 2026-0235 Coroner: Paul Rogers Area: Inner West LondonThis report is being sent to: NHS England | One London Board | London Ambulance Service NHS Trust | South London and Maudsley NHS Foundation Trust | The College of Policing | The Comm 6 responses identified · 6 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified gaps in police officers' understanding of Mental Health Act powers and insufficient assessment of an individual's situation. Concerns were also raised regarding the fragmented sharing and visibility of healthcare records across multiple agencies.

Responses identified 6 of 6

Coroner's concerns

AI summary
The coroner identified gaps in police officers' understanding of Mental Health Act powers and insufficient assessment of an individual's situation. Concerns were also raised regarding the fragmented sharing and visibility of healthcare records across multiple agencies.
View full 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). [REDACTED] 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 [REDACTED] 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 that 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.

Responses

6 respondents

OneLondon Board

Indexed date: 24 Apr 2026 PDF
AI-classified response stance Action Planned
AI-generated response summary

• The eMHA by Thalamos system has been introduced in most London Mental Health Trusts, with s136 status developed with the Metropolitan Police now live, and s135 planned for delivery this year. • Work is underway to build mental health care and crisis plans within the Universal Care Plan (UCP), with funding secured and connection to the National Record Locator (NRL) established. • A procurement exercise for future London Care Record systems has commenced, with essential criteria to include pan-London information sharing from all Mental Health Trusts and a user interface that alerts staff to important patient information.

View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths - Edward Muwanga who died on 7th August 2023 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24th April 2026. Before responding to the specific concerns raised in the Report, we would like to express our deep condolences to Edward’s family and loved ones. The OneLondon Board is keen to assure the family and yourself that the concerns raised about the integration and accessibility of patient health care records which contain important patient information about risks they may present to themselves and others have been listened to and reflected upon. Your Report raises concerns about the training and application of the Mental Health Act by our strategic partner Metropolitan Police. It also raises concerns about the integration and accessibility of patient health care records which contain important patient safety information about risks that a patient may present to themselves and others, and the sharing of information that will assist a clinician or health and care professional with little or no knowledge of the patient to make properly informed decisions about treatment or risk management. We understand the concerns raised in the Report. The OneLondon Board recognise the importance and duty to share information. We fully understand that making the right information available to health and care professionals at the right time can save lives and improve the safety and quality of the treatment and care our patients receive.

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In consideration of the concerns raised within the PFD report, OneLondon have taken active part in several review meetings with participants from London Ambulance, NHS England (London Region), and South London and Maudsley NHS Foundation Trust. We have agreed joint working to continue improvements that are already underway and committed to continue to work closely with partner organisations to ensure mental health and patient safety remains central to future developments.

1) Background information on OneLondon This background information explains OneLondon. It also outlines the relevant national NHS systems and OneLondon systems that were referenced in this case. OneLondon is not a statutory body – but it is a ‘collaboration’ that was created in May 2018 across the NHS in London. It includes the NHS Integrated Care Systems (ICSs), London Ambulance Service, NHS England (London region), the Greater London Authority and London’s Health Innovation Networks. The aim of the collaboration is to improve the sharing of information to support more effective and more joined up care for Londoners. (Ref: https://onelondon.online/) OneLondon has a governance framework with senior decision-makers, and their responsibilities include agreeing our work plan, monitoring performance against this and ensuring we always operate to the highest standards. Members include representatives from NHS England London, each of the Capital’s Integrated Care Systems, London Ambulance Service and other partners. There are three ‘OneLondon’ IT systems that are used across London that are relevant to this case –
1) Universal Care Plan – this is a regional care planning system available in London
2) eMHA – this is a regional system used to digitise the Mental Health Act in London by many (but not all) of our Mental Health Trusts and LAs
3) London Care Record – this is a regional shared care record available in London These systems can all be used alongside other national systems – such as the National Care Records Service (NCRS) and the National Record Locator (NRL). LCR London Care Record – this is a regional shared care record for London UCP Universal Care Plan – this is a regional care planning system for London NCRS National Care Records Service – this is a national system that supports the sharing of some patient information National Care Records Service - NHS England Digital

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NRL National Record Locator – this is a national system that enables the sharing of documents. It is part of NCRS. It is widely used by Mental Health Trusts in the country to share ‘Crisis Plans’ that are held within their own electronic patient record systems (EPRs). National Record Locator (NRL) - NHS England Digital

Edward Muwanga died on 7th August 2023. The Report explains that before his death, there was interaction with the London Ambulance Service (LAS) Clinical Hub, London Ambulance clinicians and with a 111 GP – and that the NHS staff accessed different systems to obtain information about Edward Muwanga. The investigation showed that either the important information about Edward Muwanga was missing, or it was very hard to find, and hence was not seen.

2) Response and actions taken Universal Care Plan (UCP) At the time of Edward Muwanga’s death, there was no Universal Care Plan (UCP) for him because UCP was not being used to support mental health care. That is now changing and work is currently underway to build mental health care & crisis plans in the UCP – and for this to be linked to Mental Health Trust electronic patient record (EPR) systems.  In 2025 work was carried out to design a ‘care & crisis plan’ to be used in the UCP. Funding was also requested to support this work. We received funding for this work (confirmed in April 2026)  The plan is to build the ‘care and crisis plans’ this year (2026/27). Work has started. (This work requires the support of all Mental Health Trusts, as well as their electronic patient record (EPR) suppliers who are the Access Group and TPP)  This project will deliver a standard template/data set that has been designed to be used, ensuring a common set of information that is shared across London – and available to London Ambulance and 111staff/clinicians. To note is that since February 2024, the UCP has been connected to the National Record Locator (NRL) system. This means that as soon as the care & crisis plans are in the UCP, they will also be accessible to everyone who uses NCRS.

eMHA At the time of Edward Muwanga’s death, London had not yet implemented the eMHA system by Thalamos. Since the death of Edward Muwanga, a new eMHA by Thalamos system has been introduced in London. This system supports the digitisation of the Mental Health Act and aims to support more joined-up assessment,

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treatment and discharge of Londoners detained under the Mental Health Act – including those being treated under Community Treatment Orders (CTOs). In most parts of London, the process for assessing and treating people under the MHA had previously relied on staff from different organisations completing and sharing a number of paper-based forms. The new eMHA by Thalamos system modernises how health and care staff access, record and share information to reduce delays and makes it easier to work together to best meet the needs of patients. Currently we are still in the process of ensuring full coverage. However, the system is live in most Mental Health Trusts and available to their partners (Local Authorities etc). The eMHA by Thalamos system is live in the following 5 Mental Health Trusts in London:  East London NHS Foundation Trust (ELFT) – November 2024  North East London NHS Foundation Trust (NELFT) – January 2025  South West London and St George’s Mental Health NHS Trust (SWLStG) – January 2025  Oxleas NHS Foundation Trust (Oxleas) – March 2025  South London and Maudsley NHS Foundation Trust (SLaM) – March 2025 The other Mental Health Trusts in London are reviewing their resources and capacity to implement the digital eMHA solution. The eMHA solution is also being used in some emergency departments (Guy's and St Thomas NHS Foundation Trust were the first).

Data from eMHA is also now shared in the London Care Record.  There is a clear ‘alerting flag’ that shows staff using the London Care Record about the existence of Mental Health Act related data when they are being treated under the eMHA.  In addition, Mental Health Act history will be displayed for 4 years. (The sharing of eMHA data with the LCR started December 2025). The following is available – o MHA Legal Status – (short & long description) o Start / end date o Detaining Organisation e.g. hospital name o Detaining Organisation Contact details (e.g. telephone number)  The following are also included as deemed of key interest to health and care professionals: o Section 2 – Detention for Assessment o Section 3 – Detention for Treatment

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o Section 4 – Detention in Emergency o Section 5 (2) – Hospital holding Powers - Doctor o Section 5 (4) – Hospital holding powers – Approved Nurse o Section 17 - Leave o CTO – Community Treatment Order There is currently no information relating to s135 (or s136) available in the London Care Record. However, health and care professionals would be able to see a CTO was in place – and some other relevant information.

The following further development is planned –  s135 is on the Thalamos roadmap – and is due to be delivered this year  Thalamos have just completed developing a s136 status with the Met Police. This is now live. (Information will therefore also be available from City Police and British Transport Police for London Region.) This is live in the Thalamos product although it is not yet shared into the London Care Record. (There are no current timescales for this – but is achievable within the next 6 months if the Mental Health Trusts and the Police Organisations agree to sharing).

It is important to note that eMHA records formal MHA processes and outcomes, including detention under the Act and legal documentation. It does not include the earlier clinical decision-making or referral processes leading up to a Mental Health Act Assessment - which is what is applicable in Edward Muwanga’s case.

London Care Record At the time of Edward Muwanga’s death, the London Care Record was being used to share information across London. This system is being used by over 100,000 staff regularly. It is fully recognised that whilst the London Care Record is an important source of information for many clinician staff and health and social care professionals, it is not perfect. There are some known issues with the content and the design, and users have fed back that it is difficult to see the most critical information quickly. The investigation showed that there was information that was being shared by South London and Maudsley NHS Trust into the London Care Record. South London and Maudsley is one of the Mental Health Trusts who are sharing information into the London Care Record that is available across London for services such as London Ambulance. There are other Mental Health Trusts who are currently only sharing information locally (within their own Integrated Care System). The information shared by South London and Maudsley included several entries that reflected an escalation in risk and concern. However, key information was recorded

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primarily within free-text clinical notes/documents rather than structured or prominently flagged fields. Hence, while this information was available via the London Care Record, it required active navigation and interpretation to identify the most relevant and recent updates. It was therefore very hard for staff (who had no prior knowledge of Edward Muwanga) to find the most relevant and pertinent information about him. The system used for the London Care Record is provided by Oracle Health. There are currently technical constraints and limitations on the ability of the NHS to change the way that the system presents information. However, we commit this year to –  Reviewing the options that we have available with the current supplier, and to understand if there are ways that the information that is being shared could be better presented – so that important information is clearly available  Actions will also be taken this year to seek to address the gaps in data sharing from Mental Health Trusts. (The budget for this work is not yet confirmed as available, but there is a route through London NHSE Regional governance to address this with Trusts, and commitment in principle has been obtained). In parallel, the current contracts for the London Care Record are due to expire in the coming years – with aligned contract end dates of March 2028 agreed. This year there is a procurement exercise that has started in London which will look at what systems we will use in London.  We commit to ensuring that the procurement specification will include as essential criteria the ability to share information pan-London from all Mental Health Trusts, and a ‘user interface’ which clearly alerts clinical staff to important and relevant information about the patient they are seeing / treated.

3) Concluding response There have been improvements to information sharing across the NHS in London since the time of Edward Muwanga’s death, in particular, the introduction of the eMHA system. There is also work in train to further improve. The focus this year is on creating a improved and standardised care plan for mental health which will also include support during times of crisis. The eMHA Thalamos system will also be further improved and where this done (e.g. for s136) it will be prioritised as additional sharing into the London Care Record. It is recognised that even with these positive changes, there remains more work that can still be done in terms of –  the sharing of information from all Mental Health Trusts in London  wider sharing with the Police, Local Authorities and AMHPs (Approved Mental Health Professionals)

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 alignment and consistency of information across OneLondon and national systems  the usability and accessibility of information within the London Care Record. We have introduced a new Delivery Oversight Group for OneLondon, and this will be asked to manage the oversight and track implementation of our plan to further improve our information sharing within our three major pan London systems (eMHA, London Care Record and Universal Care Plan as from June 2026). Through this, OneLondon will continue to seek to improve information sharing to support safer Mental Health care for Londoners.

It is also relevant to note that the government has announced work on a Single Patient Record. (Ref NHS England » Single Patient Record – your health at your fingertips ) Whilst this is not available yet, this is important work which should improve the safety of care across the country. OneLondon is already fully engaged in the programme and will encourage its development for use within mental health and patient safety.

Thank you for bringing these important patient safety issues to our attention, and please do not hesitate to contact us should you need any further information.

NHS England

NHS / Health Body
Letter dated 23 Jun 2026 PDF
AI-classified response stance Action Taken
AI-generated response summary

• NHS England has implemented the Frontline Digitisation Programme to support NHS trusts in adopting Electronic Patient Record systems and improving digital maturity. • An initiative has been set to achieve national interoperability between shared care records across England. • NHS England's Regulation 28 Working Group discusses all PFD reports to share learnings and insights across the NHS.

View full response
Dear Mr Rogers, Re: Regulation 28 Report to Prevent Future Deaths – Edward Muwanga who died on 7th August 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24th April 2026 concerning the death of Edward Muwanga on 7th August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Edward’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Edward’s care have been listened to and reflected upon.

Your report raised concerns around the sharing and visibility of important health care records between medical agencies. In this case, particularly between the treating Trust, in this case South London and Maudsley NHS Foundation Trust (SLAM) and NHS 111, and between the Ambulance Service Trust and SLAM.

NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. As of 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold, the core information standard, between providers within their own integrated care board footprint through their local Shared Care Record. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

23rd June 2026

NHS England recognises that limited information sharing between care settings can reduce the continuity and effectiveness of care, particularly where patients are receiving support across multiple organisations. NHS England has developed and led the Frontline Digitisation (FD) Programme to support NHS trusts in adopting Electronic Patient Record (EPR) systems, improve digital maturity, and enable better information sharing within and between organisations. In addition to supporting the procurement of EPR systems, the FD Programme provides guidance and oversight to help ensure that implementations are safe and effective. The South London and Maudsley (SLAM) NHS Foundation Trust This trust uses the CareNotes Electronic Patient Record (EPR) system supplied by OneAdvanced (formerly Advanced). As part of the Frontline Digitisation (FD) Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the Digital Capability Framework (DCF). Through the FD Programme, the Trust secured funding to support development of a business case to replace its current EPR system.

London Ambulance Service NHS Trust This Trust uses an electronic Patient Care Record (ePCR) system supplied by Cleric Computer Services Ltd. As part of the FD Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the DCF. Through the FD Programme, the Trust has secured funding to invest in additional functionality to support its EPR, including:
• A new patient centred Computer Aided Dispatch (CAD) system, linked to its mobile electronic Patient Care Record (ePCR) system
• Improved front-line interoperability with other Ambulance Services and One London Emergency Departments (ED) as a pilot.
• Joining up the patient record by linking with ED systems
• Optimisation of the EPR across the Ambulance Trust and associated treatment centres. Both trusts can already securely share important health care records electronically with health and care partners through the OneLondon Care Record, using a Health Information Exchange (HIE) supplied by Oracle Health. However, while Section 136 status should be recorded within the originating mental health record (in this case SLAM), this would not necessarily be included in the OneLondon Care Record.

Further information about information sharing between providers Local EPR implementations should operate under the oversight of a Trust Clinical Safety Officer (CSO). The CSO is a registered healthcare professional responsible for overseeing the clinical safety and risk management of health IT systems, helping to

ensure that these systems are safe for patient use. Digital safety is a critical component of patient safety. Suppliers and Trusts are jointly accountable for compliance with the two mandatory Clinical Risk Management Standards defined under Section 250 of the Health and Social Care Act 2012:
• DCB0129: Clinical Risk Management: its Application in the Manufacture of Health IT Systems - NHS Digital
• DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems Where multiple digital systems are used within a trust, including EPR systems, robust policies and procedures should be in place to set clear expectations, support appropriate clinical record management, and ensure the timely handover and escalation of abnormal results to the relevant individuals. Responsibility and accountability for the sharing and management of information held within electronic records, including information shared across different systems, rests with each organisation through its established digital governance arrangements. While the FD Programme supports investment in local digital capability, interoperability is generally configured and managed locally, based on agreements between provider organisations and their technology suppliers, with NHS England regional teams taking account of wider catchment areas where appropriate. It is also relevant to consider how the Summary Care Record (SCR) and National Care Records Service (NCRS) may have supported clinical care in this case. Given that Edward had a diagnosis of paranoid schizophrenia, it would be reasonable to expect that this diagnosis, together with any medication prescribed for that condition, would be visible in his SCR, provided that he had not opted out. Brief additional clinical information, for example regarding auditory hallucinations, may also have been included. However, the SCR does not contain correspondence and would therefore be unlikely to include communications between SLAM and the police, nor any recent information relating to sections 135 and 136, unless these were identified by the responsible clinician as explicitly needing to be coded or included as additional information for sharing. Similarly, the National Record Locator, as a separate service within NCRS, is also unlikely to contain that specific correspondence.

National Care Records Service (NCRS) NCRS is the successor to the Summary Care Record application (SCRa) and is designed to address barriers to adoption identified in a number of care settings. The National Care Records Service (NCRS) provides a quick and secure way to access national patient information in order to support clinical decision-making and improve healthcare outcomes. It is free to use and includes additional features and services beyond the legacy SCRa product.

NCRS is internet-based, accessible through a web browser, and is actively used by the London Ambulance Service (LAS) across a range of devices. We would expect both the LAS and NHS 111 to have access to patients’ Summary Care Record (SCR) through NCRS. Any further enquiries about access to SCR through NCRS should therefore be directed to LAS.

Summary Care Record (SCR) NCRS provides access to patients’ Summary Care Records. The SCR is a national record containing key patient information such as current medication, allergies, and details of any previous adverse reactions to medicines. It is generated from GP medical records, and changes made to the GP record are synchronised to the SCR. The SCR can be accessed and used by authorised staff in other parts of the health and care system who are involved in the patient’s direct care but do not require access to the full GP record. Its purpose is therefore to provide a concise summary of the patient’s GP record, including the information most likely to be helpful during an unscheduled care encounter. As a minimum, the SCR contains important information about:
• Current medication
• Allergies and details of any previous reactions to medicines
• The name, address, date of birth and NHS number of the patient In addition, details of long-term conditions, significant medical history, and specific communication needs are now included by default for patients with an SCR, unless they have previously told the NHS that they do not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR Where information is communicated to the GP, for example, via discharge summaries, crisis event notifications, or correspondence, relevant details may be coded or attached within the GP record. If appropriately recorded and coded, this can be visible within the Summary Care Record (SCR) as Additional Information. However, this is not guaranteed, as it depends on:
• Whether the mental health provider shares the information
• Whether the GP system receives and codes it
• Whether it is included within the SCR upload and subsequently viewed

Additional Information in the SCR includes the active problems and significant past problems (from Optum/TPP/Medicus provider systems) for a patient as recorded by their registered GP practice. In relation to SCR, as of 27 April 2026, 88% of the population of England (approximately 59 million patients) had an SCR with Additional Information, 7.3% had

a Core Only SCR (allergies and medications only), and 1.5% had opted out of SCR. In most cases, patients must give Permission to View before their SCR can be accessed. However, an Emergency Access option is available where a patient is unable to provide Permission to View, for example because they are unconscious. National Record Locator NHS England’s National Record Locator (NRL) service allows health and social care professionals to identify and access patient information shared by other health and social care organisations across England in support of direct patient care. It does this by recording the location of digital and paper records within the NHS and providing an index of pointers or bookmarks that can be used to retrieve key patient information from the source. The aim is to improve interoperability across organisational boundaries and support professionals, including care coordinators in mental health trusts, to retrieve information securely and remotely at the point of need. This can help provide a more longitudinal view of a patient’s records and indicate their treatment history. The NRL avoids the need for organisations to create duplicate copies of information across systems by facilitating access to up-to-date information directly from the source. It can also indicate which organisations currently have a care relationship with a patient, enabling users to contact the relevant service in the event of a crisis. Mental health crisis plans are one of the pointer types supported by the NRL service. NRL does not store mental health data, or clinical content itself; rather, it points users to where that information can be found. NRL information can be accessed through the National Care Records Service (NCRS). Where multiple pointers are returned, users can sort the results by creation date. If a mental health provider publishes relevant documents (e.g. care plans, discharge summaries), these may be discoverable via NRL. However, there is no consistent assurance that Section 136 status is explicitly shared or published, and visibility depends on local publishing and role based access and governance practices.

Connecting Care Records NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records, which bring together records from different health and care organisations in one place and connect information around the individual rather than a single organisation. Shared Care Records include prescribed medications and will typically contain more information about an individual than a Summary Care Record. Responsibility for delivering shared care records rests with local Integrated Care Boards (ICBs). Each ICB develops its shared care record in response to local health and care needs, existing systems, and future plans. As a result, some shared care records are accessible to neighbouring ICBs, while others operate only within their own area. Future plans include improving connectivity so that shared care records can be used more consistently across England, regardless of where a person lives or receives care.

Further investigation may be required to determine the extent of the relevant trusts’ access to SCR, NRL and Shared record in this case. More broadly, NHS England and the Department of Health and Social Care have published Fit for the Future: 10 Year Health Plan for England, which sets out the government’s plan for healthcare in England over the next decade. The Plan includes a commitment to give patients ‘a single, secure and authoritative account of their data
– a single patient record’ to support more coordinated, personalised and predictive care.

Regional Response

NHS England have liaised with One London Board who have detailed their response and actions following this Report. As they will be providing a response directly to the Coroner we won’t provide further details here.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Edward, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

College of Policing

Police / Law Enforcement
Letter dated 19 Jun 2026 PDF
AI-classified response stance Action Planned
AI-generated response summary

• The College of Policing stated it would ensure the points highlighted in the report are fully considered within any amendments made during the formal review of its Authorised Professional Practice (APP) guidance. • The College of Policing noted that the Metropolitan Police Service (MPS) is providing a full response to the operational elements and decision-making processes raised in the report. • The College of Policing stated it hosts the implementation toolkit for the 'Right Care Right Person' (RCRP) initiative and supports forces with its implementation.

View full response
Dear Mr Rogers Thank you for providing the College of Policing with a copy of your report dated 24th April 2026 following the death of Edward Muwanga. We extend our sincere condolences to his family and all those affected. We have carefully considered the matters of concern raised in your report and provide the following response on behalf of the College of Policing. In relation to the operational elements and decision-making processes, we have been in contact with the Metropolitan Police Service (MPS) and understand that a full response to these points is being provided. The College of Policing recognises the risks associated with mental health incidents and we understand the critical importance of decisions about the appropriate response to such calls. The police response to mental health incidents is covered within the guidance produced by the College under the Authorised Professional Practice (APP). The APP is currently going through a formal review and we will ensure that the points highlighted within your report are fully considered within any amendments made within the review process. The College is a co-signatory to the National Partnership Agreement (NPA) which sets out ‘Right Care Right Person’ (RCRP), which is a national partnership initiative that aims to ensure that vulnerable people get the right support from the right services and seeks to work to end the inappropriate and avoidable involvement of police in responding to incidents involving people with mental health needs. Where it is appropriate for the police to be involved in responding, this will continue to happen, however the police should only be involved for as long as is necessary, and in conjunction with health and/or social care services. The College host the implementation toolkit for RCRP and works closely with the National Police Chiefs’ Council to continue to support forces with the implementation of this policy. I would like to reassure you that we are working hard to ensure that our APP and guidance are continually reviewed to provide forces with the tools, training and support to deal appropriately with the concerns that you have raised. The College are reassured by the MPS who are taking substantive steps to strengthen training, policy, and operational practice in this area.

We hope this reassures you of our continued commitment to supporting police forces in reviewing and refining operational processes and policies in response to concerns raised. Please do not hesitate to contact us should you require any further information.

Metropolitan Police Service

Police / Law Enforcement
Indexed date: 24 Apr 2026 PDF
AI-classified response stance Action Taken
AI-generated response summary

• Officers receive comprehensive training on sections 135 and 136 of the Mental Health Act, including their application in communal areas and the execution of section 135 warrants. • Section 135 warrants are now recorded on police intelligence systems accessible to all officers, and processes for managing police assistance at warrants have been strengthened. • Enhanced supervisory oversight and escalation processes are embedded within control room decision-making for mental health incidents.

View full response
Dear Mr Rogers, Thank you for your Regulation 28 Report dated 24 April 2026 concerning the tragic death of Mr Edward Muwanga. I The Metropolitan Police Service (MPS) extends its deepest condolences to the family of Mr Muwanga and we take the concerns you have raised extremely seriously. This letter sets out the formal response of the Commissioner of Police of the Metropolis, addressing each matter of concern and outlining the actions taken and planned to reduce the risk of similar incidents occurring in the future. I can confirm that the matters of concern you. set out within your Regulation 28 report have been carefully considered by senior leaders and practitioners within the MPS and I would now like to formally respond to as follows: The first matter of concern is as follows: 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 The MPS acknowledges the findings of the inquest and the concerns raised in this report, and we have taken substantive steps fo strengthen training, policy, and operational practice. All officers now receive structured and comprehensive training on sections 135 and 136 of the Mental Health Act. This includes specific instruction on the lawful use of section 136 powers in communal areas, with explicit clarification reinforced through operational notices issued to all frontline staff. Officers are also trained on the purpose and execution of section 135 warrants, including the respective roles of health professionals and the importance of safeguarding considerations. Training is delivered through a blended approach, combining classroom learning, scenario-based exercises, and ongoing professional development to ensure both legal understanding and effective practical application. In addition, officers are expected, as best practice, to conduct intelligence checks when attending ·
• mental health incidents, enabling the identification of warrants and relevant risk information at the earliest opportunity. Pao 1 of ?

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South London and Maudsley NHS Foundation Trust

NHS Trust
Letter dated 16 Jun 2026 PDF
AI-classified response stance Action Taken
AI-generated response summary

• South London and Maudsley NHS Foundation Trust (SLaM) undertook a comprehensive internal review of its information sharing practices. • The London Care Record (LCR) has been implemented across all London mental health trusts, enabling access to relevant mental health information. • SLaM is engaged in ongoing work to standardise crisis care plans and integrate them into a Universal Care Plan (UCP) model within the LCR.

View full response
Dear Mr Rogers

Re: Inquest into the Death of Edward Muwanga who died 07.08.2023 - Response to Regulation 28 Report

I write in response to the Regulation 28 Report to Prevent Future Deaths in the case of Edward Muwanga. Specifically I write in response to the matters raised which are relevant to (i) NHS England, (ii) OneLondon Board, (iii) London Ambulance Service NHS Trust (“LAS”), and (iv) South London and Maudsley NHS Foundation Trust (“SLaM”), and to provide you with SLaM’s responses to the concerns you have raised.

Evidence was heard at the inquest, and SLaM notes that concerns have been raised as follows:

I. 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 [SLaM] and NHS 111, and between the [LAS] (not NHS 111) and the treating Trust (SLAM).

II. Evidence was heard from LAS 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.”

III. Written evidence was received from LAS 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."

IV. 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.

1. Review of SLaM information sharing
1.1 Approach to the review In response to the concerns identified by you, Sir, SLaM undertook a comprehensive internal review. The purpose of the review was to examine:
• the information recorded in relation to this patient, and
• the extent to which that information was available to other organisations at the relevant time. South London and Maudsley NHS Foundation Trust Office of the Chief Executive Maudsley Hospital Denmark Hill London SE5 8AZ

The review was led by SLaM’s Chief Clinical Information Officer who was supported by senior clinical, operational, and patient safety staff. The review included a detailed examination of:
• the patient’s clinical records held within the Trust,
• information shared via the London Care Record (LCR), and
• documented interactions between organisations involved in the patient’s care.

1.2 Platforms used to record and share information

Electronic Patient Journey System (“ePJS”)

Within SLaM, patient information is primarily recorded in the Electronic Patient Journey System (“ePJS”), which has served as the Trust’s main electronic health record and central repository for clinical documentation since 2002.

The London Care Record (“LCR”)

Since March 2023, SLaM has adopted a London-wide sharing approach to ensure that appropriate information is available to clinicians at the point of need, regardless of where the patient presents.

The approach to sharing information through the LCR was developed in partnership with service users, families, and carers. This collaborative design prioritised the sharing of up-to-date contextual information about a patient’s current clinical presentation, rather than relying solely on single structured data points, which may not fully reflect the person’s most relevant situation.

Relevant information recorded in ePJS is shared automatically with the LCR in near real time. This includes:
• important alerts
• care team information
• the most recent 15 progress notes
• discharge notification summaries
• key clinical correspondence

Within the LCR, information from ePJS is presented under sections headed ‘Mental Health’ and ‘Clinical Correspondence’. This is consistent with arrangements across other London mental health trusts. The LCR is a secure digital platform that enables authorised health and social care professionals to access key patient information from multiple organisations, providing a shared view to support clinical decision-making.

Crisis plans

Crisis plans provide guidance to support decision-making in anticipated crisis scenarios. They are recorded in ePJS and shared via the National Record Locator Service (known as NRLS or NRL). Taken Crisis Plans and LCR together, these sources can support continuity of care and clinical decision-making at the point of clinical need.

The Universal Care Plan (“UCP”)

The UCP forms part of the broader LCR programme, and it has been developed and implemented incrementally across London, with key shared care record capabilities established by April 2024 as part of a national NHS England initiative.

Within this evolving digital infrastructure, there are ongoing developments to standardise crisis care planning across all London mental health trusts and to incorporate this information into a UCP model within the LCR.

This is intended to provide a more consistent and visible approach to sharing crisis-relevant information across organisations, complementing existing clinical records.

The UCP is also designed to support patient access through the NHS App and, in future, may enable closer integration with core electronic patient record systems. This would facilitate more timely updates as a patient’s clinical presentation changes, reduce duplication across systems, and improve the availability of relevant information to clinicians at the point of need.

The electronic Mental Health Act system (“eMHA”)

The eMHA by Thalamos is a digital platform used by five Mental Health Trusts in London to complete, process, and securely share statutory Mental Health Act documentation across organisations involved in a patient’s care. It was implemented locally in SLaM from 24 March 2025, as part of a London‑wide programme to improve the accuracy, timeliness and accessibility of MHA documentation.

The primary purpose of eMHA is to provide a longitudinal, structured record of Mental Health Act activity, including applications for detention, medical recommendations, treatment and renewal forms, and records of detention. It enables authorised professionals, including AMHPs, doctors and mental health law teams, to complete and share statutory forms electronically, supporting more coordinated and efficient care.

It is important to note that eMHA records formal MHA processes and outcomes, such as detention under the Act and subsequent legal documentation, rather than the earlier clinical decision-making or referral processes leading up to a Mental Health Act Assessment which applied to this case. For this reason, referrals for MHAA and wider clinical context remain recorded within the main clinical record (e.g. ePJS). In addition, while eMHA provides a structured record of MHA activity from its point of implementation, it does not retrospectively capture all historical detentions prior to go live. From 2026, information on current MHA status is also reflected in the London Care Record, to support cross organisational information sharing.

NHS 111 Mental Health

To facilitate timely access to specialist advice, support and triage in mental health crises, the NHS 111 mental health service became available to South London residents in December
2023. From 1 April 2026, the SLaM 24-hour mental health crisis line was transitioned into NHS 111 Mental Health. As a result, NHS 111 Mental Health became the single 24-hour access point for patients, carers, the public, and professionals seeking urgent mental health support.

Clinical safety of information sharing platforms

The information available through shared platforms is intended to support, but not replace, clinical assessment. It provides guidance to clinicians and should be interpreted alongside direct assessment of the individual and, where appropriate, discussion with relevant services. This may include:
• NHS 111 Mental Health services (single point of access),
• conveyance to a health-based place of safety, or
• consultation with the patient’s treating team during working hours.

1.3 Information available for this patient

At the time of the events in question, the patient was under the care of a SLaM Community Mental Health Team and was recognised to be experiencing a deterioration in mental health.

This information was recorded within the ePJS (Electronic Patient Journey System) and shared to the LCR (London Care Record). Information visible within the LCR “Mental Health” section included documentation of clinical deterioration, referral for a Mental Health Act Assessment (MHAA), and ongoing liaison with the Approved Mental Health Professional (AMHP) service and supported accommodation staff. These entries reflected an escalation in clinical concern, including that the patient was awaiting an MHAA. A crisis plan dated 22 April 2023 was also available via the National Record Locator Service (NRLS), providing general guidance for the patient’s management in crisis situations. However, documentation relating to an AMHP warrant reportedly obtained on 2 August 2023 was not present within ePJS and was therefore not available to be shared via the LCR.

It is important to consider the significance and presentation of the information available. A referral for an MHAA reflects professional concern regarding a potential escalation in risk, while the presence of a Section 135(1) warrant represents a further escalation with legal authority for assessment. In this case, key information regarding the patient’s deterioration and level of risk was recorded primarily within free-text clinical notes rather than structured or prominently flagged fields. While this information was available via the LCR, it required active navigation and interpretation to identify the most relevant and recent updates.

At the time (2023), the LCR was in relatively early stages of adoption, and clinicians may also have relied on crisis plans accessed via NRLS. While the LCR provided up-to-date clinical context, crisis plans are inherently more general and may not reflect recent changes such as deterioration or a pending MHAA. In addition, the LCR provides a curated subset of the full clinical record and requires users to actively retrieve and interpret information across multiple entries. As such, while relevant information was available across systems, its visibility and immediate accessibility depended on familiarity with, and active use of, these platforms. Clinical judgement and, where necessary, direct communication between services therefore remained essential.

2. Discussions and joint learning with LAS, NHS England and OneLondon Board

In addition to the internal review, SLaM has engaged with the London Ambulance Service (LAS), NHS England and the OneLondon Board to reflect on the learning from this case, including the concerns raised during this inquest into the death of Edward Muwanga. These discussions have focused on how information is recorded and shared across multiple digital systems, and the risks that may arise from fragmentation, variable visibility of information, and differences in system use across organisations.

These multi-agency conversations have highlighted both the significant progress already achieved in developing shared care records and digital interoperability across London, and the ongoing work required to improve the consistency, visibility and timeliness of critical information. Partners recognised the need to mitigate risks during this period of transformation, including improving the prominence of key risk indicators, strengthening system integration, and supporting staff to effectively access and interpret information across platforms.

It is recognised that where a patient with severe mental illness is awaiting a Mental Health Act Assessment, this represents a period of increased clinical risk. Reflecting on this case, SLaM and LAS have identified that, in such circumstances, additional active information-seeking and clinical assessment may be required to support safe decision-making. It is also acknowledged that digital systems, while supportive, do not replace the need for direct clinical communication

between services, particularly where there are concerns regarding risk or deteriorating presentation. Clinicians have access to NHS 111, including the mental health option, on a 24-hour basis to support advice, triage and escalation where required.

3. Developments with respect to the sharing and visibility of important health care records since 2023 and ongoing

Since 2023, there have been significant developments across London to improve the sharing, visibility and accessibility of mental health information, particularly in crisis situations. The LCR has been implemented across all London mental health trusts, and it is used routinely in clinical practice, enabling organisations such as the London Ambulance Service (LAS) and NHS 111 to access relevant mental health information for direct clinical care. This has improved the ability of clinicians to view key information across organisational boundaries. In addition, from April 2026, the transition of local crisis lines into the NHS 111 mental health service has provided a single, 24-hour access point for crisis support, supporting more consistent triage and escalation across the system.

Alongside these developments, there has been increased focus on training, standardisation and system usability, including the consistent presentation of mental health information within the LCR and improved staff awareness of shared records. However, learning from this case has reinforced that, despite improved availability of information, in complex situations, challenges remain regarding the visibility of key risk indicators across systems, and the need for active information-seeking and interpretation by clinicians in time-critical situations.

Relevant to this case, there is ongoing work within the London Digital Mental Health Forum to standardise crisis care plans across mental health trusts in London, with the intention of incorporating these into a UCP model within the wider LCR (London Care Record). This work seeks to address current fragmentation, whereby crisis plans and clinical information may sit in separate systems, by improving the consistency, visibility and accessibility of crisis-relevant information across organisations. A key aim is for the UCP to integrate with core electronic patient record (EPR) systems such as ePJS, enabling information to be shared without duplication and to reflect changes in a patient’s clinical presentation in a more timely manner. This programme of work is ongoing and aligns with wider NHS ambitions to improve integration between digital systems and move towards a more cohesive and accessible patient record, supporting safer and more efficient care across organisational boundaries.

Learning from this case has been discussed in a multi-agency forum focused on the management of Mental Health Act assessments, involving SLaM, local authority partners and other agencies. These discussions have specifically considered the role of information sharing in supporting timely and safe decision-making during periods of escalating risk. SLaM has also confirmed its willingness to engage with the LCR working group from July 2026, to contribute to system-wide improvements in the sharing and visibility of clinically relevant information across organisations.

4. Concluding remarks

This case highlights the complexity of information sharing across a multi-organisational healthcare system. Since 2023, there have been important advances in how clinical information is shared across organisations in London, in particular, with the established LCR, which enables secure, near real-time access to information from each organisation’s electronic patient record; in addition, crisis plans are also shared via NRLS. There is now greater emphasis within training on both accessing shared information (which is ‘read-only’ via the LCR) and actively sharing relevant information from within each organisation’s electronic patient record, recognising the need to support care beyond organisational boundaries.

More broadly, care pathways are increasingly structured to distinguish between routine care and crisis situations, with clear routes for escalation through the NHS 111 single point of access. In addition, specialist systems, such as the electronic Mental Health Act (eMHA) platform, support information sharing at later stages of the Mental Health Act process following a decision to detain.

While no single system currently provides a fully integrated, real-time view of all patient information, these developments represent meaningful progress in improving visibility of key information and supporting safer decision-making across organisations. The Trust recognises that safe clinical decision-making depends not only on the availability of information, but also on the ability of clinicians to identify and interpret it, alongside effective communication between services in crisis situations.

SLaM remains committed to working with system partners to further strengthen information sharing, improve consistency and usability of shared records, and support safe, coordinated care across organisational boundaries.

NHS Ambulance Service

NHS / Health Body
Letter dated 16 Jun 2026 PDF
AI-classified response stance Action Taken
AI-generated response summary

• The Trust has implemented digital flagging and visual prompts within clinical systems to alert clinicians to shared care plans and key documents. • Training materials and clinical guidance have been reviewed and updated to reinforce expectations for accessing shared care records and seeking safety information. • The Trust has invested in improved integration between electronic patient care records and the London Care Record platform, and enabled functionality to improve visibility between internal systems.

View full response
Dear Sir

Re: Inquest into the death of Edward Muwanga - Regulation 28 Prevention of Future Death Response

I write in response to the Regulation 28 Prevention of Future Deaths (PFD) Report issued following the inquest into the death of Edward Muwanga. In advance of responding to the specific concerns raised in your report, I would like to extend my sincere condolences to Mr Muwanga’s family and loved ones. London Ambulance Service NHS Trust (“the LAS”) is keen to assure the family and yourself that the concerns raised have been listened to and reflected upon.

Your report has raised the following concerns:

The integration and accessibility of patient health care records which contain important patient safety information about risks they may present to themselves and others, and more generally contain information that will assist a treating clinician with little or no knowledge of the patient to make properly informed decisions about treatment or risk management Following the conclusion of the above inquest, and in consideration of the LAS evidence previously outlined in detail by way of disclosure of a joint Patient Safety Incident Investigation Report, witness statements and live evidence heard during the course of the Inquest hearing, the Trust will address your concerns below. LAS recognises and accept the Coroner’s concerns raised regarding the accessibility and visibility of critical patient information, and the challenges faced by clinicians in identifying key risk factors in time pressured emergency situations.

Current Position:

At present, the platforms that are available to LAS clinicians to facilitate access to patient information are through a range of systems (Appendix 1), which include the London Care Record (LCR), National Care Records Service (NCRS), National Record Locator (NRL) and Universal Care Plan (UCP). All of these facilitate sharing of information on secure platforms.

These systems provide access to extensive clinical information; however, the Trust recognises that:
• Critical risk information may be embedded within lengthy unstructured documentation.
• Clinical information may be not published consistently across different systems (e.g. the availability of Mental Health Crisis Plans published via the National Record Locator are not accessible via the London Care Record).
• Not all care plans or safety plans are consistently recorded in a format designed for rapid identification.
• Records produced by one organisation may not be immediately visible or prioritised in another organisation’s clinical systems.
• Clinicians unfamiliar with a patient or the originating organisation’s record structure may find it difficult to identify key risk information at the point of care.
• There is currently no nationally mandated approach to sharing of key clinical information, nor how patients can access and modify this information – though there is a national Single Patient Record programme in train which may address certain issues. LAS acknowledges that access alone does not guarantee effective use, and that how information is structured, highlighted, and prioritised is fundamental to patient safety. In consideration of this and the Coroner’s concerns raised within the PFD report, the Trust has recently facilitated meetings with participants from NHS England (London Regional ICB’S), OneLondon and South London & Maudsley NHS Foundation Trust (SLaM) to discuss these findings. These meetings were arranged to ensure that all considerations have been explored in relation to the visibility of pertinent information providing an opportunity for improved awareness of the challenges faced by LAS and partner organisations. It also provided an overall understanding that better integration, the ability to surface key critical information quickly and the developments by future digital improvements are essential to the prevention of future harm. The Trust will continue to work closely with partner organisations to ensure patient safety remains central to future developments.

Actions Taken - Planned and Ongoing Work: LAS recognises that improving integration and accessibility of patient risk information requires a system-wide approach and continued collaboration with partner agencies and key stakeholders in digital platforms. Ongoing and planned activities include: Promotion of Universal Care Plans The Trust has and continues to highlight the clear benefits to our partners in the development of UCP for shared care plans across organisations. Digital Flagging and Visual Prompts Enhancements have been implemented (Appendix 2) within clinical systems to alert clinicians when a shared care plan or key document exists, prompting review at the point of care. This is intended to reduce the likelihood that critical information is overlooked due to time pressures in clinical interactions or where patient data records contain a volume of information. Training and Clinical Guidance Training materials and clinical guidance have been reviewed and updated to reinforce expectations regarding:
• When and how shared care records should be accessed.
• The importance of actively seeking documented care plans and safety information. These updates are embedded within induction, mandatory training, and ongoing clinical communications. Improved System Integration The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS. From the 12th of May, functionality to improve visibility between internal systems has been enabled (notably, the visibility of information currently only visible within the Computer Aided Dispatch [CAD] system in ePCR), which will assist clinicians to access extra incident information, and support decision-making. This will provide the additional benefit of improved visibility of information which has been received by other providers into our CAD (e.g. from the Metropolitan Police Service (MPS) or NHS 111 services).

LAS Mental Health Team - Actions Taken - Planned and Ongoing Work

Recent updates undertaken have strengthened the emphasis on accessing care records and obtaining collateral information in Mental Health assessments. The ePCR Mental Health Documentation Tool (launched in November 2025) now includes embedded Mental Health assessment guidance prompting crews to review care records, with further enhancements to be proposed through planned and ongoing work.

Alongside this, training within LAS has been expanded significantly to include:

• An updated induction session for frontline staff on Mental Health.
• Conference teaching delivered by the LAS Mental Health Practice Lead.
• A new rolling training programme which covers case-based discussions and reinforces these practices.
• Targeted sessions for different staff groups.
• Accessible resources such as the Crisis Management video series which is available to all frontline staff and covers shared decision making, obtaining collateral information and accessing care.

Improved communication with Mental Health Services A further development which has occurred since the conclusion of the inquest has been the introduction of a single point of access for mental health services. This is a relatively new 24/7 NHS 111 telephone service which is delivered by SLaM, and will support LAS clinicians with access to collateral information and direct clinical advice to inform referrals and onward care. Full regional rollout across South London is planned by the end of summer 2026. This development will improve shared decision making and awareness of 999 interaction, which will assist in obtaining pertinent information for patients related to their mental health, current circumstances and offers the opportunity to discuss potential deterioration.

Electronic Mental Health Act (eMHA) Electronic Mental Health Act (eMHA) information is now available in the London Care Record via the eMHA Thalamos system. The system has been introduced at five of London’s Mental Health Trusts and their partner organisations - East London NHS Foundation Trust, North East London NHS Foundation Trust, Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust. LAS clinicians can see whether a patient is or has been detained under the MHA, including dates and the responsible organisation, with data retained for four years after detention ends.

This will assist to support safer, more informed decision-making at the point of care. If an MHA status is shown, this will likely prompt contact with the detaining organisation for further details.

Key points:
• Shows current or past MHA detention status, dates, and organisation.
• Acts as a prompt to gather further information.
• Improves patient oversight, assisting in coordination and improved patient safety.
• It is recognised that currently not all cases will appear, as not all organisations use the system.
• This is a new development which currently is not available pan-London, and is dependent on Trusts who have engaged with the system. Collaboration with System Partners The Trust continues to work collaboratively with the London regional NHS and Integrated Care Boards, Acute Trusts, Mental Health providers, and national programme teams to promote consistent use of shared care planning tools and improve understanding of how information recorded by one organisation is accessed and used by another.
• LAS is actively involved and participates in the One London board, as the only pan- London NHS provider organisation. Other representation is at an ICB and regional level. Consideration will be given to developing further enhancements to improve interoperability between the LCR and the NRL– notably the consumption of NRL records in the LCR in the first instance, with a longer-term view to also share information from the LCR into the NRL. This will be achieved through influence over the direction of procurement and strategic planning of the OneLondon 2.0 programme and approach to London Care Record, UCP and enhanced access and integration.

• At an operational level, LAS has a touchpoint every other month with the Universal Care Plan team and are part of the UCP Clinical Transformation & Advisory Group. The LAS will be collaborating with the UCP team to develop the next two specific personalised care planning use cases – mental health and catheter care. As part of this learning, consideration for how information may be consistently shared across the correct platforms will be made. In addition, the UCP have received confirmation of funding which will allow them to develop integrations into two key Electronic Patient Records (Rio and Mosaic) to support the sharing of mental health information in the UCP. As previously referred to, strategically and operationally, LAS continued to influence this and the wider OneLondon programme to ensure increasing alignment between LCR and UCP – this is informed by the learning access from Mr Muwanga’s case, but also other cases where access to information would support safer, better care.

• LAS’s paramedic Chief Clinical Information Officer and Deputy are part of the NHS England Single Patient Record Programme Clinical Reference Group. The SPR programme aims to create one unified, secure view of a patient’s health and care information across NHS services in England. This intends to bring together data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will focus on two identified priority areas (maternity and frailty) before looking to further areas. It is intended that the first priorities will go live around 2028.

• Some concerns have been raised with the SPR programme from groups including the British Medical Association and Unions about data security, confidentiality and access. This proposal forms part of wider NHS reforms intended to streamline services and improving patient care and outcomes.

Conclusion: London Ambulance Service NHS Trust recognises the seriousness of the concerns raised, and the importance of ensuring that clinicians have access to the right information, at the right time, in a format that supports safe and effective decision-making. LAS remains fully committed to continued collaboration and engagement with partner organisations to strengthen information sharing, improve usability and contribute to system- wide solutions that support safe informed clinical decision making, and prevent future harm. In addition to this, the LAS recognise that further Single Patient Record developments are likely to change the digital landscape in forthcoming years ahead of our continued commitment to collaboration. I hope this information is of assistance in responding to your Regulation 28 concerns.

Report sections

Investigation and inquest
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 inquiries as to the existence of the section 135 MHA  1980 warrant, when information could have been obtained that addressed that. The ambulance crew assessed Eddi 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 2226 on 6th August 2026 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.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power  to take such action.
Copies sent to
I can confirm I have sent the report to:  [please do not use individual’s names, but instead roles/titles]2.NHS England3.South London and Maudlsey NHS Foundation Trust 4. London Ambulance Service NHS Trust5. The OneLondon Board6. The College of Policing7. The Commissioner of Police for the Metropolis

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Report details

Reference
2026-0235
Coroner
Paul Rogers
Coroner area
Inner West LondonThis report is being sent to: NHS England | One London Board | London Ambulance Service NHS Trust | South London and Maudsley NHS Foundation Trust | The College of Policing | The Comm

Responses identified

Responses identified 6 of 6
All listed responses identified

Sent to

London Ambulance Service NHS Trust
NHS England
One London Board
South London and Maudsley NHS Foundation Trust
College of Policing
Commissioner of the Metropolitan Police

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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