Recurring concern

Insufficient CCTV monitoring of access to high-risk locations

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First reported 21 Nov 2013•Latest report 3 Apr 2025

Definition

What this concern includes

Includes inadequate CCTV coverage or active monitoring of approaches, entrances and access to locations identified as presenting a serious fall, self-harm or comparable safety risk.

Not included

  • CCTV used for unrelated crime detection or retrospective evidence only
  • Direct staff observation where CCTV is not the identified control
  • General CCTV technology concerns without a high-risk access function
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Hampshire County Council1
Kennedy Wilson Europe1
Midlands Partnership University NHS Foundation Trust1
National Highways1
Oldham Borough Council1
Recipient name withheld1
Savills1
Savills Management Resources Limited1
Spindles Town Square Shopping Centre1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. City of London

    AI-generated summary

    Alexander Adnan Cardoza · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alexander Adnan Cardoza, a 16-year-old child, died on 27 March 2025 after falling from a location in the City of London. The principal concerns were that barriers remained surmountable, could potentially be assisted by horizontal wiring and a movable object, and that operational security was insufficient to prevent the fall; there was also no CCTV security camera monitoring of the location. The report identifies an ongoing risk of further deaths, noting that two deaths had occurred in similar circumstances.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of CCTV security camera monitoring

    Wider context from the report

    “1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

    Source location

    Alexander Adnan Cardoza · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Seth Curtis Palminder · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of monitored CCTV coverage of the bridge and approach area

    Wider context from the report

    “3. There are no known monitored CCTV cameras covering the bridge or approach area, rendering monitoring of a recognised danger spot actionless. 4. At the incident location, according to Hampshire Police Record Management Systems, there have been 12 crisis incidents in the last 5 years (of which the Police are aware) - including 7 self-harm (jumping) attempts, 2 successful jumps from which the individual has survived and 3 fatalities. There have been a further 89 known 'concern for safety' incidents at the location. ”

    Source location

    Seth Curtis Palminder · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add the location to the South East Network Needs list for future funding prioritisation.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Apply for future funding for a study into preventing future suicide events at the location.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.

    Verbatim wording from the response

    “The bridge at ████████ over the A3(████████) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3(████████) corridor, regardless of their primary usage. The ████████ bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used by pedestrians and cyclists.”

    Source location

    Response from Hampshire County Council
    Page 1 · response
    Published 20 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 2022

    Open published response

  3. Shropshire, Telford and Wrekin

    AI-generated summary

    Lee William Davies · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lee William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of CCTV coverage of the garden area

    Wider context from the report

    “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am; (2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair; (3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence. (4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair. (5) The deceased was admitted to the Centre with a known substance abuse problem; (6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure; (7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use; (8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015. (9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants; (10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage; (11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken; (12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding. (13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area. (14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients. ”

    Source location

    Lee William Davies · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester North

    AI-generated summary

    Lisa Jane CLAYTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lisa Jane Clayton had severe clinical depression and a history of self-harm attempts. On 27 June 2012, she went missing from home and was found at the foot of The Spindles car park after being seen on the wall surrounding its seventh floor. The principal concerns were that the wall and rails provided insufficient prevention of access, CCTV monitoring and security-control-room staffing were inadequate, and previous concerns about suicide attempts at the location had not led to sufficient action.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient CCTV monitoring of access to and usage of the 7ᵗʰ floor

    Wider context from the report

    “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself. 2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1. 3) The wall/rails are an insufficient deterrent/preventative measure. 4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor. 5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room. 6) There have been previous acts and attempts by others to take their own life, at the same location. Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles. In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same. Despite this, little direct action has (or appears to have) been taken. ”

    Source location

    Lisa Jane CLAYTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026