Evan Dandou-Dambelle: Prevention of future deaths report
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Date of report: 29/10/2025
Ref: 2025-0549
Deceased name: Evan Dandou-Dambelle
Coroner name: Mary Hassell
Coroner Area: Inner North London
Category: Suicide (from 2015)
This report is being sent to: East London NHS Foundation Trust
| Regulation 28: Prevention of Future Deaths report | |
|---|---|
| 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 [REDACTED]. He was at the time experiencing symptoms of psychosis and command hallucinations. |
| 5 | CORONER’S CONCERNS 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. 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 |