West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA Tel: 0208 753 6800 Email: ealingandhillingdoncoroners@lbhf.gov.uk

Date: 30 June 2025 Case: 35521132

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: CGL (Ealing RISE) 1 CORONER I am Lydia Brown Senior Coroner for West London 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 INVESTIGATION and INQUEST On 21 June 2024 I commenced an investigation into the death of Ella Colette La- India DAVID-FONG. The investigation concluded at the end of the inquest . The conclusion of the inquest was Drug related death 1a Metonitazene and alprazolam intoxication 1b 1c II 4 CIRCUMSTANCES OF THE DEATH

Ella was found collapsed on the street outside her home and resuscitation was attempted, but she dIed in Ealing Hospital later the same day on 17 June 2024. She had taken a number of illicit drugs that resulted in an unintentional drug overdose. She had a long history of illicit drug use and although she was engaging with services she was unable to abstain or achieve recovery. 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. - Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective theraputic relationships as well as required under the legal framework. (1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue. The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn. Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing.

6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 1st September 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 Chief Coroner and to the following Interested Persons
- family
- West London NHS Trust

I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 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 by the Chief Coroner. 9 30 June 2025

Signature

Lydia Brown Senior Coroner for West London

Confidentiality and sharing information When someone you care about is accessing our services, it’s natural to want to be kept updated. However, we need to ensure that people using our services are able to do so confidentially if they wish. This leaflet explains how confidentiality works, when treatment information can be shared with you, and how you can stay involved. What is confidentiality? Confidentiality means protecting someone’s personal information. It applies when information is given on the understanding it will be kept private – such as when you give information about your health to your GP. When someone engages with Change Grow Live’s services and tells us about themselves, we keep that information private unless there’s a very important reason not to. When might information be shared? The most common way we’re able to share information is with the agreement of the person using our services. This is called ‘consent’. It is really important that people engaging with us can decide when and how we can share information with those supporting them. Not only is this the right position legally, it also helps us build stronger relationships and trust with the people we support. In limited circumstances, we might share information with you without the consent of the person using our services. ?

What you can do Even if the person using Change Grow Live’s services does not want us to share information about them, you can still play a really valuable role in their recovery whilst respecting their privacy. You can share information with us if something’s worrying you, or tell us things you’ve noticed. This isn’t a breach of confidentiality in the legal sense, but we might not be able to use what you’ve shared without it being obvious to the person that you have spoken with us. For that reason, we encourage you to be open with your friend or relative wherever possible. How we discuss consent We will talk to your friend or family member regularly to get their views on who we can share information with. We respect their decision, and we ensure they’re given regular opportunities to tell us if their views have changed. We let them know that having a supportive network outside of treatment can bring many benefits. We share materials about consent and choices so they are fully aware of their right to confidentiality, and when we might share information. Registered Charity Number 1079327 (England and Wales) and SC039861 (Scotland). Company RegistrationNumber 3861209 (England and Wales). About Change Grow Live We help people to change the direction of their lives, grow as individuals, and live life to its full potential. Find out more at changegrowlive.org /changegrowlive @changegrowlive @changegrowliveuk @changegrowlive For example, if the person lacks capacity to make their own decisions, or if we feel there is a risk of serious harm to someone and we need to share information to prevent this. Even in these rare cases, we only ever share what is necessary. Additional information and support If you have any questions, you can ask your local service, or email dataprotection@cgl.org.uk It's also really important to look after yourself, so do talk to your local service to find out about families’ and carers’ services in your area. You can also speak with someone via our family and friends webchat:

advice-info/family-friends We can tell you about our general service offerings and possible treatment pathways, but we won’t be able to tell you which one applies to your friend or family member. i