Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0146, written 5 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 May 2023 |
|---|---|
| Reference | 2023-0146 |
| Deceased | Callum Wong |
| Coroner | Peter Straker |
| Coroner area | London (North) |
| Category | Child Death (from 2015) · Suicide (from 2015) |
| 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.
Her Majesty’s Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
North London Coroners Court,
29 Wood Street,
Barnet EN5 4BE
E-mail:- admin.beh@hmc-
northlondon.co.uk
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Department of Health and Social Care,
33 Victoria Street,
London SW1H 0EU
1
CORONER
I am Peter Straker, Assistant coroner, for the coroner area of Northern District of
Greater London
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On the 31st August 2022 I opened an investigation touching the death of Callum Wong
who was 17 years old when he died. I opened an inquest on the 23rd September 2022.
The inquest concluded on the 27th February 2023. The conclusion of the inquest was
“Callum Wong killed himself ”, the medical cause of death was 1a Asphixia, 1b Hanging
(suspension) and under paragraph 2 Mental Health Issues and Asthma.
4
CIRCUMSTANCES OF THE DEATH
On the 27th August 2022 Callum Wong was found having hanged himself
Mr Wong had had suicidal thoughts in the past but having been supported by his
family, overcame them. When Mr Wong had suicidal thoughts again, patient
confidentiality issues resulted in those from whom he sought help, not informing his
family.
5
CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. –
1. Consideration for exceptions to patient confidentiality in cases of mental
illhealth, where informing third parties of a patient’s condition may result in
crucial non-medical support.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 Wednesday the Twenty-Eighth of June 2023 I, the assistant coroner, may
extend the period.
Her Majesty’s Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;-
-
The Family
Mental Heath Trust
Department of Health
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 coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
3-5-2023
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