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recurance

Agnès Marchessou

26 Nov 2020 · Coroner Mary Hassell · Inner North London

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

No concerns could be extracted with a verified quote. Read the original report.

Linked reports

Repeats an earlier warningEdir DA Costa27 Jun 2019 · 1 year 5 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
Original on judiciary.uk ↗

This report

“The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms [name redacted] to hospital, nor to any of the doctors or nurses at the hospital.”
Full chain: Police fail to convey critical health information to ambulance crew

Responses

2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf ↗· Metropolitan Police

Stated action · shortly

“The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error