Evan Dandou-Dambelle

I am:   Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court Bow Coroner’s Court

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.

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.

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.

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