Edward Muwanga

DATE OF REPORT 24 th April 2026

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power  to take such action.

On 7 th September 2023, an inquest into the death of Edward Muwanga was  opened who died on 7 th August 2023 aged 36 years. The inquest was held and concluded with a jury between 19 th – 27 th January 2026 and 3-4 March 2026 Findings of the Jury: The medical cause of death was 1(a) Multiple trauma How, when and where On August 7th 2023, Edward Muwanga entered  Queensway London Underground Station. He  descended on to the trackway, where he was struck  by a train, which resulted in his death. Based on the  evidence provided, we find that the following matters were probably causative of his death: a) The actions of Eddie when entering the track; and b) There was a delay by central line controllers in notifying the driver to slow down and/or stop the train. There are a number of failings or omissions that we wish to record: 1) The Care Co-ordinator was made aware that a warrant to section Eddie was granted on 2nd August 2023. This information was not provided to Eddie’s  assisted living facility. 2) As a consequence, when Police and Ambulance crews attended Eddie’s assisted living facility on 6th August 2023, (following reports of him walking into  oncoming traffic), they were not made aware of the warrant having been granted. Similarly, the 111 NHS doctor who discharged Eddie from the Ambulance’s care made their decision to do so without this crucial information. 3) The LAS attendee provided limited information and details regarding Eddie’s condition to the NHS 111 doctor. Notably, the record of their call indicates that the 111 NHS doctor inferred from his comments that Eddie would be watched closely by employees in his assisted living facility in the hours that would follow. This led to them agreeing to the discharge. 4) The LAS NHS Trust made a series of admissions about the NHS 111 doctor as follows: a) There was a failure to communicate with Eddie directly on the 6th August 2023 during the course of his assessment; and b) There was a failure to communicate  with Eddie’s community mental health team. These acknowledged shortcomings did not affect the outcome. 5) The Police’s visit to Eddie’s assisted living facility was cursory in nature. They left after spending no  more than ten minutes discussing his prior actions, his condition and the plans for his oncoming care and wellbeing. The haste with which they departed –  having failed to take reasonable steps to check the  status of the warrant – is a noteworthy omission, and  indicative of a cavalier attitude to someone in a  mental health crisis. A more detailed, measured and  thoughtful assessment of Eddie’s situation was  warranted. 6) The Police officers who attended Eddie on 6th  August 2023 did not properly understand their powers under Section 136 MHA 1983. Conclusion Accidental Death: Caused by Eddie’s entry on to the trackway. We do not believe he intended to die.