Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0549, written 29 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Oct 2025 |
|---|---|
| Reference | 2025-0549 |
| Deceased | Evan Dandou-Dambelle |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) |
| 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: Prevention of Future Deaths report
Evan Amon DANDOU-DAMBELLE (died 02.05.25)
THIS REPORT IS BEING SENT TO:
1. Chief Medical Officer
East London NHS Foundation Trust (ELFT)
Robert Dolan House
Trust Headquarters
9 Alie Street
London E1 8DE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Poplar Coroner’s Court
Bow Coroner’s Court
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 13 May 2025, one of my assistant coroners, Ian Potter, commenced
an investigation into the death of Evan Dandou-Dambelle. The
investigation concluded at the end of the inquest on 21 October 2025. I
made a determination at inquest of death by suicide.
4
CIRCUMSTANCES OF THE DEATH
Whilst at home on the evening of 2 May 2025, Evan Dandou-Dambelle
He was at the time experiencing symptoms of
psychosis and command hallucinations.
5
CORONER’S CONCERNS
1
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my 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.
When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary
meeting on 9 April 2025, his level of contact was changed from red
(weekly) to amber (fortnightly). This was the last MDT before his death.
This was also the point when the consultant psychiatrist decided to stop
his olanzapine that day and commence risperidone, titrating it up
gradually. However, the psychiatrist did not suggest that, in deciding the
level of contact (red being weekly; amber fortnightly; and green monthly),
the medication change was worthy of particular consideration.
Even if the consultant had raised the medication change for particular
consideration, the team might still have decided to move Mr Dandou-
Dambelle to amber, and even if they had kept him on red, it might not
have impacted on the outcome.
However, in deciding level of contact from the mental health services, it
does seem worthy of automatic consideration that the patient’s
medication has been altered significantly.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 24 December 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 following.
2
• The mother, sister and fiancée of Evan Dandou-Dambelle
• HHJ Alexia Durran, the Chief Coroner of England & Wales
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. She may send a copy of this report to any person who
she 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 SIGNED BY SENIOR CORONER
29.10.25
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.
Office of the Chief Medical Officer Trust Headquarters Robert Dolan House 5th Floor 9 Alie Street London E1 8DE Private & Confidential HMC Mary Hassell 23 December 2025 Dear Madam RE: REGULATION 28 REPORT - Evan Amon Dandou-Dambelle I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 29 October 2025 following the inquest touching the death of Mr Evan Amon Dandou- Dambelle. You noted a concern as follows: When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death. This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration. Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome. However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly. Trust Response The Trust agrees that for all cases discussed within multidisciplinary meetings in community mental health services, including specialist services such as Early Intervention Services, any significant proposed or enacted changes to medication should be considered and discussed as part of the decision making process related to care planning and future contact arrangements. Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too. I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026. Conclusion I hope this response provides sufficient reassurance to you and to the family of Mr Dandou-Dambelle. I would like to offer my sincere and heart-felt condolences to his family at this difficult time. Yours sincerely Chief Medical Officer
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