Edward Muwanga
24 Apr 2026 · Coroner Paul Rogers · Inner West London
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. failure to assess mental health crisis in communal space
“A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the [name redacted]'s situation”
2. lack of awareness of section 135 MHA 1980 process
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers”
3. fragmented health record visibility
“The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM)”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation”
This report
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant”
Closely relatedConfidence 0.92 · high
Earlier report
“if an application had been submitted to the magistrates' court that day, it is unlikely that the warrant would have been executed before Mrs [name redacted] death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates' court and executed by the police was in the region of 2 weeks.”
This report
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.”