Prevention of Future Deaths reports · 2025

Sidi Bojang

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 report1 Aug 2025
Reference2025-0436
DeceasedSidi Bojang
CoronerAndrew Walker
Coroner areaLondon (North)
CategorySuicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Department for Health and Social Care (PDF)
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,

Related reports

Other reports by Andrew Walker

See all →

More reports categorised “Suicide (from 2015)”

See all →

Track Suicide (from 2015)

See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.