Ella David-Fong

I am Lydia Brown Senior Coroner for West London CORONER’S LEGAL POWERS

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

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.

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information to assist family and carers in how they can  share concerns and communicate information when consent is withdrawn.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.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action