Ella David-Fong

West London Coroner Service 
25 Bagleys Lane, Fulham, London, SW6 2QA 
Tel: 0208 753 6800 Email: ealingandhillingdoncoroners@lbhf.gov.uk  

Date: 30 June 2025 
Case: 35521132 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  CGL (Ealing RISE) 
CORONER 

I am Lydia Brown Senior Coroner for West London  
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 
INVESTIGATION and INQUEST 

On 21 June 2024 I commenced an investigation into the death of Ella Colette La-
India DAVID-FONG. The investigation concluded at the end of the inquest . The conclusion 
of the inquest was 

Drug related death 

1a   Metonitazene and alprazolam intoxication 

1b    

1c    

 II     
CIRCUMSTANCES OF THE DEATH 

Ella was found collapsed on the street outside her home and resuscitation was attempted, 
but she dIed in Ealing Hospital later the same day on 17 June 2024. She had taken a 
number of illicit drugs that resulted in an unintentional drug overdose. She had a long history 
of illicit drug use and although she was engaging with services she was unable to abstain or 
achieve recovery. 
CORONER'S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In my 

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 opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  - 

Ella had a very supportive and engaged family, but at times she withdrew consent from the 
agencies trying to provide care and support and refused for information to be shared with her 
family.  As a capacious adult she was entirely able to make this decision, and the agencies 
had to respect this.  The important information the family had was not therefore shared to 
assist with and improve Ella's care.  Confidentiality and consent are key concepts in 
establishing the trust necessary to build effective theraputic relationships as well as required 
under the legal framework. 

(1) It was acknowledged at inquest that there is currently inadequate information provided for 
family and carers regarding this challenging issue.  The court was advised that it would be 
appropriate to provide further information at the commencement of treatment both by leaflets 
provided to the family and carers and on the website to set out the legal position of consent 
and confidentiality, together with information to assist family and carers in how they can 
share concerns and communicate information when consent is withdrawn.  Currently there is 
no effective information of how communications can be received, without breaching the 
confidentiality requirements and this was stated to be a learning point for Ealing RISE at the 
inquest hearing.   

ACTION SHOULD BE TAKEN 

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In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action. 
YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 1st September 2025. I, the coroner, may extend the period. 

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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. 
COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons  
 - family 

 - West London NHS Trust 

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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. 
30 June 2025 

  
  
  
  
 Signature 

Lydia Brown Senior Coroner for West London

Confidentiality and  
sharing information

When someone you care about is accessing our services, 
it’s natural to want to be kept updated. However, we need 
to ensure that people using our services are able to do so 
confidentially if they wish.
This leaflet explains how confidentiality works, when 
treatment information can be shared with you, and  
how you can stay involved.

?

What is confidentiality?

Confidentiality means protecting 
someone’s personal information.  
It applies when information is given 
on the understanding it will be kept 
private – such as when you give 
information about your health to  
your GP.

When someone engages with 
Change Grow Live’s services and  
tells us about themselves, we keep 
that information private unless 
there’s a very important reason  
not to.

When might information  
be shared?

The most common way we’re able 
to share information is with the 
agreement of the person using our 
services. This is called ‘consent’.

It is really important that people 
engaging with us can decide when and 
how we can share information with those 
supporting them. Not only is this the right 
position legally, it also helps us build 
stronger relationships and trust with   
the people we support.

In limited circumstances, we might 
share information with you without 
the consent of the person using our 
services.  

 For example, if the person lacks capacity 
to make their own decisions, or if we feel 
there is a risk of serious harm to someone 
and we need to share information to 
prevent this. Even in these rare cases, we 
only ever share what is necessary.

We can tell you about our general 
service offerings and possible treatment 
pathways, but we won’t be able to tell 
you which one applies to your friend or 
family member.

How we discuss consent

We will talk to your friend or family 
member regularly to get their views on 
who we can share information with.  
We respect their decision, and we ensure 
they’re given regular opportunities to tell 
us if their views have changed.

We let them know that having a 
supportive network outside of treatment 
can bring many benefits.

We share materials about consent and 
choices so they are fully aware of their 
right to confidentiality, and when we 
might share information.

What you can do 

Even if the person using Change Grow 
Live’s services does not want us to 
share information about them, you can 
still play a really valuable role in their 
recovery whilst respecting their privacy.

You can share information with us if 
something’s worrying you, or tell us 
things you’ve noticed. This isn’t a breach 
of confidentiality in the legal sense, 
but we might not be able to use what 
you’ve shared without it being obvious 
to the person that you have spoken with 
us. For that reason, we encourage you 
to be open with your friend or relative 
wherever possible.

Additional information  
and support 

If you have any questions, you can 
ask your local service, or email 
dataprotection@cgl.org.uk 

It's also really important to look after 
yourself, so do talk to your local service  
to find out about families’ and carers’ 
services in your area. 

You can also speak with someone  
via our family and friends webchat:  
www.changegrowlive.org/
advice-info/family-friends 

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About Change Grow Live 

We help people to change the 
direction of their lives, grow as 
individuals, and live life to its  
full potential. 

Find out more at  
changegrowlive.org

/changegrowlive

@changegrowlive

@changegrowliveuk

@changegrowlive

Registered Charity Number 1079327 (England and Wales) and SC039861 (Scotland). Company RegistrationNumber 3861209 (England and Wales).