Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0366, written 18 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jul 2025 |
|---|---|
| Reference | 2025-0366 |
| Deceased | Marie Theobald |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Road (Highways Safety) related deaths · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MR G IRVINE
SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
Ref: 25877844
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
, The Commissioner of Police of the Metropolis
Sent via email:
&
1
CORONER
I am Graeme Irvine, senior coroner, for the coroner area of East 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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 23rd December 2023 I commenced an investigation into the death of Marie Louise
Theobald aged 48 years. The investigation concluded at the end of the inquest on 18th
July 2025.
Following an autopsy Ms Theobald’s medical cause of death was determined as;
1a Severe Traumatic Head and Spinal Injuries
An inquest was opened on 9th January 2024 and two separate scheduled inquests have
been adjourned, pending the outcome of a criminal investigation.
As of 18th July 2025 no charging decision has been made in this tragic case.
1
4
CIRCUMSTANCES OF THE DEATH
Ms Theobald (48) was the pedestrian victim of a fatal road traffic collision on 22nd
December 2023. The deceased was walking her dogs metres from her home in
Chigwell. At 17.09 she was struck by a car travelling at high speed on a single
carriageway domestic road. The car failed to stop. A vehicle was identified and a
suspect was detained.
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1.
Ms Theobald was killed over 18 months ago. Delays in the criminal
investigation mean that an identified suspect is neither subject to conditional
bail, driving disqualification nor are they remanded in custody. The absence
of these measures means that a risk of further fatal harm exists.
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 15th September 2025. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the family of Mrs Theobald. I have also sent it to the local Director of Public
Health who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
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.
9
[DATE] 18/07/2025 [SIGNED BY CORONER]
2
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr Graeme Irvine Senior Coroner East London Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A 2JL 12/09/2025 By email Dear Mr Irvine, Prevention of future deaths – Marie Louise Theobald I would like to start by expressing my sincere condolences to the family and friends of Marie Louise Theobald. Our thoughts and sympathies are very much with them. On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matter of concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths dated 18 July 2025 following the Pre Inquest Review into the tragic death of Ms Marie Louise Theobald. The MPS has acknowledged and reviewed the matter of concern raised in your Regulation 28 Report and responds as follows: The Coroner’s “Matter of Concern” Ms Theobald was killed over 18 months ago. Delays in the criminal investigation mean that an identified suspect is neither subject to conditional bail, driving disqualification nor are they remanded in custody. The absence of these measures means that a risk of further fatal harm exists. MPS Response to “Matter of Concern” To answer the Matter of Concern, I have addressed two separate issues: the potential for further fatal harm caused by the driver and the delays in the criminal investigation. Potential for further fatal harm In all cases where a suspect is arrested for driving causing death or serious injury, officers review all options to limit the chances that the suspect may commit further offences. This includes a review by Operation Revoke, where the MPS works together with DVLA to see if the driver’s licence can be revoked, liaising with employers where the collision took place in the suspect’s line of work, the implementation of bail conditions and where relevant, interim prosecution for more minor driving offences. Following the arrest on 23 December 2022, the suspect was bailed with stringent conditions, designed to prevent driving. On two occasions, bail was extended without a change to the conditions. On 16th MORE TRUST LESS CRIME HIGH STANDARDS September 2024, police made an application to the Magistrates court for the suspect’s bail, with its conditions, to be extended. Extension of bail was denied. The reasoning given by the court was that the suspect was already, at that time, disqualified from driving for a period of time as I refer to below. Prior to the bail period ending, the suspect had been charged by the investigation team with an offence under S172 of the Road Traffic Act, resulting in a disqualification from driving for 6 months. The driver remains disqualified from driving until September 2026, having been found guilty of an unrelated offence in July 2025. While I appreciate that there has been a period from 21 January 2025 until 11 July 2025 that the driver was not disqualified or under bail conditions not to drive, I hope it will provide some comfort to the family and reassurance to the Coroner that the suspect is currently disqualified from driving until September 2026. I apologise for the fact that the Officer in the Case was unaware of this disqualification at the time of the Pre-Inquest Review hearing and that therefore you were not made aware of this important fact at the time your report was issued. This is something the officer’s line manager has discussed with the officer. Delays in the criminal investigation When discussing the length of this Serious Collision Investigation, there are a number of factors that have caused delays in this case. This type of investigation is lengthy by its very nature, and Ms Theobald’s family were informed, and showed understanding of this, at the beginning of the investigation and during regular contact with the Family Liaison Officer. Delays in serious collision investigations are typically encountered in forensic processes and technical reports, and reviews of computerised processes, as well as CPS reviews. The investigation team started engagement with the CPS Mid-2024 and continue to liaise with assigned lawyers. Due to the ongoing Criminal Investigation, I cannot disclose which forensic processes have caused delays in this case, however I am satisfied that this was outside of the control of the investigating officers. In addition to the above, delays occurred due to staffing challenges, leading to the current investigating officer inheriting a relatively large number of cases to be progressed simultaneously. The Serious Collision Investigation Unit has recently recruited a number of new detectives which will increase the capacity of the unit and ensure cases are processed expeditiously. Since the start of this investigation, the leadership team overseeing the Serious Crime Collision Unit has changed and processes have been, and are being, implemented to ensure the effective and efficient functioning of the unit. The current Senior Investigative Officer has completed a full review of the case, which they have briefed me on. The Officer in the Case is working through the final actions for which he has been given strict deadlines, and I anticipate that all reports will have been received back as early as is reasonably possible. The MPS will be providing you with an update every two months as to the outstanding actions and anticipated time frames until the conclusion of this investigation. I hope this response explains the delays in the investigative process and clarity around the interim disqualification of the driver since this tragic incident that gave rise to your matters of concern. I apologise once again that this information was not made available to you during the Pre Inquest Review. Please do not hesitate to contact me should you require any additional information or clarification regarding the above. Yours sincerely, Deputy Assistant Commissioner Met Operations and Performance
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