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recurance

Jake Girton

29 Sept 2025 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. failure to notify hospital of release

    “Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which [the deceased] was arrested was under an obligation to inform that complainant (the hospital) of [the deceased]'s release from custody. There is no evidence to suggest this was done. Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that [the deceased] would remain in police custody, and had they known he was released, greater efforts may have occurred to support [the deceased] in the community.”
  2. 2. lack of identified shortcomings and remediation

    “Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with [the deceased], consequently no evidence exists of any reflection or remediation of this failing.”

Responses

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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.

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