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recurance

Sidi Bojang

1 Aug 2025 · Coroner Andrew Walker · North London

The coroner's concerns

  1. 1. discharge of mentally ill patient without psychiatrist review

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse.”
  2. 2. unrecognized mental health crisis leading to fatal train collision

    “Mr [name redacted] was clearly unwell and had attended the Accident and Emergency department the day before complaining of a "wooshing" sound and seeing flashes of light when he was triaged. He had attended with feelings of self-harm and had reported an attempt to cut his wrist and stab himself”

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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Sidi Bojang · Recurance