Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0193, written 22 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2018 |
|---|---|
| Reference | 2018-0193 |
| Deceased | Alexia Walenkaki |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Alexia Awenimi WALENKAKI (died 17.07.15)
THIS REPORT IS BEING SENT TO:
1. Mr Will Tuckley
Chief Executive
Tower Hamlets Council
Mulberry Place Town Hall
PO Box 55739
5 Clove Crescent
London E14 2BG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
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.
4
CIRCUMSTANCES OF THE DEATH
1
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
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
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.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 20 August 2018. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Tower Hamlets Safeguarding Children Board
, Alexia’s mum
I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
22.06.18
3
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