Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0429, written 19 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2025 |
|---|---|
| Reference | 2025-0429 |
| Deceased | Kwabena Amoateng |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
MR G IRVINE
SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Nursing Officer, South East London ICB
Chief Executive Officer, South-East London Integrated Care
1.
2.
System
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 24th September 2024, this Court commenced an investigation into the death of
Kwabena Amoateng aged 17 years.
Following an autopsy Kwabena’s medical cause of death was determined as;
“1a Multiple organ failure
1b Severe acute respiratory distress syndrome
1c Acute negative pressure pulmonary oedema
1d Congenital Hypoventilation Syndrome, Upper airway obstruction.
II Primary pulmonary hypertension, hyaline membrane disease, lobar pneumonia”
1
An inquest was opened on 08/01/2025 which concluded on 4th July 2025 after a one-
day hearing
The Inquest resulted in a narrative conclusion.
Narrative conclusion:
Kwabena Amoateng died in hospital on 23rd September 2024.
Kwabena was a 17yr old boy who suffered from congenital central hypoventilation
syndrome ('CCHS') a condition that impeded his ability to regulate his own breathing.
Kwabena was treated with non-invasive ventilation.
On 16th September 2024 Kwabena developed gastrointestinal symptoms consistent
with an infection. Infections are known to exacerbate the symptoms of CCHS and
properly, his mother escalated her concerns to Kwabena's doctors.
On 18th September 2024 Kwabena's mother called 111 who sent an ambulance to
assess her son. The ambulance crew referred Kwabena for GP assessment as he was
not found to be critically unwell or in need of hospital based treatment. Later that night,
as no out of hours GP service was available for a child, Kwabena's mother called 111
again, a second ambulance attended in the early hours of 19th September 2024 and
although Kwabena's symptoms had developed he was not deemed to be critically
unwell, was not assessed to be conveyed to hospital and was referred for GP care.
A Paediatric Respiratory Action Plan ('PRAP') had been produced by Kwabena's
specialist doctors to inform healthcare professionals on how to treat his complex
condition in the event of an emergency. That document was not available to
paramedics who assessed him on 18th or 19th September 2024. Had the PRAP been
available, it is probable that Kwabena would have been escalated for hospital
admission.
On the evening of the 21st September 2024 Kwabena became unwell whilst eating, he
collapsed. CPR was commenced by his parents and 999 was called. An ambulance
attended promptly and experienced significant difficulty in managing his airway.
Kwabena was transported to hospital where he was diagnosed with aspiration
pneumonia.
At hospital Kwabena suffered a cardiac arrest, he was resuscitated and transferred to
intensive care. There, despite maximal treatment he developed acute respiratory
distress syndrome and died on 23rd September 2024.”
ourt CIRCUMSTANCES OF THE DEATH
Kwabena Amoateng, a 17 yr old boy died in hospital on 23rd September 2024.
Kwabena suffered from congenital central hypoventilation syndrome ('CCHS').
Kwabena fell ill on 16th September 2024, numerous contacts occurred with healthcare
professionals over the next 5 days, including his GP, the 111 service, and the London
Ambulance Service. It was not until the 21st September 2024 that he was eventually
taken to hospital by ambulance where he subsequently died on 23rd September 2024.
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. –
2
1. The inquest found that a critically important document had been produced by
his specialist respiratory doctors to assist emergency healthcare professionals
in understanding his rare and potentially dangerous condition - CCHS. The
document, A Paediatric Respiratory Action Plan ('PRAP') set out the necessary
steps to be considered should Kwabena fall ill.
2. During Kwabena’s final illness, those assessing him from 16th-21st September
2024 were unaware of this vital document as it had been mislabelled and
misfiled within the online records available to them.
3. Had the PRAP been more prominently filed it is likely that those assessing
Kwabena would have escalated his treatment to admission to hospital far
earlier, which may have resulted in Kwabena’s life being saved.
4. An investigation into why the PRAP was not visible to emergency services in
this case has highlighted that there is no coordinated process to ensure a
consistent approach in producing and storing such documents in online clinical
records.
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 14th November 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 Kwabena Amoateng, CDOP. 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 September 2025 [SIGNED BY CORONER]
3
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