Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0436, written 1 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2025 |
|---|---|
| Reference | 2025-0436 |
| Deceased | Sidi Bojang |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health 1 CORONER I am Mr Andrew Walker, HM senior coroner for the coroner area of Northern 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 22nd July 2024 I commenced an investigation into the death of Sidi Chax Bojang, aged 34. The investigation concluded at the end of the inquest on the 22nd July 2025. The conclusion of the inquest was Consequences of an untreated mental health condition. The medical cause of death was 1a Multiple Injuries. 4 CIRCUMSTANCES OF THE DEATH On the 19th July 2024 at about 16.41 Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train passing through the station. Mr Bojang was clearly unwell and had attended the Accident and Emergency department the day before complaining of a “wooshing” sound and seeing flashes of light when he was triaged. He had attended with feelings of self harm and had reported an attempt to cut his wrist and stab himself Mr Bojang had sought help from the hospital but after assessing him and, as he said he felt better and agreed to see his GP, was allowed to leave. It is likely that Mr Bojang was seriously ill, and may have had auditory and visual hallucinations and this was not recognised when he was examined. The symptoms may have been incorrectly attributed to his use of cocaine taken the week before and drinking beer and whiskey 2-3 times a week. On the day he died Mr Bojang called an ambulance at 04.53 in the morning saying he had cut himself hospital by the time the psychiatric liaison team had arrived. and was taken to the A&E Department at 07.30 but had left the 1 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. – Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR] your organization 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 Friday 26th 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: Family Members. Barnet Psychiatric Liaison Team 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. 1st August 2025 9 2
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.
Parliamentary Under-Secretary of State for
Women’s Health and Mental Health
39 Victoria Street
London
SW1H 0EU
17 December 2025
Mr Andrew Walker
Barnet Coroner’s Court
29 Wood Street
High Barnet
EN5 4BE
Dear Mr Walker,
Thank you for the Regulation 28 report of 1 August 2025 sent to the Department of Health and Social
Care about the death of Sidi Chaz Bojang. I am replying as the Minister with responsibility for mental
health and I am grateful for the additional time you have allowed for me to do so.
Firstly, I would like to say how saddened I was to read of the circumstances of Sidi’s death and I offer
my sincere condolences to his family and loved ones. The circumstances your report describes are
very concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns that if a psychiatrist had reviewed the patient presenting before discharge,
Sidi’s death may have been prevented, and such action may reduce the risk of death for other people
in a similar position. It also raises concerns about the arrangements for a patient’s discharge under
such circumstances.
In preparing this response, my officials have made enquiries with NHS England to ensure we
adequately address your concerns.
I would like to assure you that NHS England has strengthened the presence of mental health expertise
within urgent and emergency care ensuring that all Type 1 Emergency Departments now have access
to 24/7 mental health liaison services. These teams are working towards Core 24 or equivalent
standards which require consultant led assessments and a timely response to individuals presenting
with mental health needs in an Emergency Department.
NHS England is continuing to work with regional teams to reinforce the expectation that all patients
presenting with self-harm or suicidal ideation receive a comprehensive biopsychosocial assessment
before discharge ensuring safe and appropriate follow-up. Alongside this NHS England is further
strengthening the urgent and emergency care mental health pathway by rolling out up to 85 Mental
Health Emergency Departments as therapeutic alternatives and by working closely with systems to
improve patient flow and reduce long waits for mental health assessments and admissions.
The Department is committed to reducing suicide rates and addressing the risk factors contributing to
suicide, as well as improving support for those who have self-harmed or are bereaved by suicide.
The Suicide Prevention Strategy for England, published in 2023, identifies middle aged men as a
priority group for targeted and tailored support at a national level. The strategy also identifies key risk
factors for suicide, providing an opportunity for effective early intervention. One of the key visions of
the strategy to reduce the stigma surrounding suicide and mental health, so people feel able to seek
help through the routes that work best for them. This includes raising awareness that no suicide is
inevitable.
In April of this year, NHS England published the Staying Safe from Suicide guidance, which
strengthens the approach to suicide prevention across mental health settings. It promotes a holistic,
person-centered approach rather than using stratification tools to determine risk.
This guidance directly aligns with the aims of our Suicide Prevention Strategy and reflects our
commitment to continually improve mental health services, particularly by identifying risk assessment
as an area where we must go further. The implementation of this guidance has been supported by a
new NHS England e-learning module, which launched in September, to help ensure that staff across
services are confident and equipped to apply the guidance in practice. And the NHS Medium Term
Planning Framework published last month states that in 2026 to 2027, ICBs must ensure mental
health practitioners across all providers undertake this e-learning and deliver care in line with the
Staying safe from suicide guidance.
In recent years, there have been many actions to prevent suicides in high-frequency locations
including on the railways. To support local areas to tackle suicides in high frequency locations and
public spaces, Public Health England (now the Office for Health Improvement and Disparities)
developed resources such as Preventing suicides in public places: a practice resource, which
provides local areas with a step-by-step guide to identifying locations and taking action.
The British Transport Police Harm Reduction Team (HaRT) is working in partnership with Network
Rail, mental health trusts and other key partners to provide support to individuals that present on
railways multiple times. A pilot project has found that, following this support, people were significantly
less likely to be present in the railway environment
You may also be
the Suicide Prevention
Support Pathfinders programme for middle-aged men. This program will invest up to £3.6 million over
3 years in areas of England where middle-aged men are at most risk taking their own lives and will
tackle the barriers that they face in seeking support.
that we have announced
interested
to hear
Furthermore, on 19 November, to coincide with International Men’s Health Day, we published the
Men’s Health Strategy. The Strategy includes tangible actions to improve access to healthcare,
provide the right support to enable men to make healthier choices, develop healthy living and working
conditions, foster strong social, community and family networks and address societal norms. It also
considers how to prevent and tackle the biggest health problems affecting men of all ages, which
include mental health and suicide, respiratory illness, prostate cancer, and heart disease.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
All good wishes,
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