Recurring concern

Unreliable land-ownership determination for safety responsibilities

First to latest report 14 Jan 2014 — 7 Aug 2024

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures in determining, verifying or recording ownership or responsibility boundaries for land where that information is needed to identify the party responsible for managing a public-safety hazard or completing remedial action.

What is not included
  • Excludes generic property, title or land-registry administration where no public-safety responsibility or hazard is involved.
  • Excludes failures to manage or repair a hazard after ownership and responsibility have been reliably established.
  • Excludes ordinary documentation deficiencies unrelated to establishing safety-relevant land ownership or responsibility.
  • Excludes broader highway, premises or environmental hazards where land-ownership determination is not the shared unsafe condition.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Malika HIBU · 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

    Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.

    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 knowledge of the ownership boundary

    Wider context from the report

    “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it. 1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody: - did not know where its ownership boundary finished; - did not risk assess the barrier to the canal; - did not act on complaints made by residents about the barrier; - having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer. 2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development. I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults. There will of course be many planning applications considered before any changes can be made to the NPPF. ”

    Source location

    Malika HIBU · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The Regulator of Social Housing assessed Peabody against regulatory standards and concluded that no further regulatory action was required.

    Verbatim wording from the response

    “The Regulator of Social Housing has engaged directly with Peabody in relation to this tragic case and having assessed all relevant information against regulatory standards, has now concluded no further regulatory action will be taken. However, the Regulator will continue its regular engagement with Peabody and note the steps that Peabody is taking in response including working with other parties to address issues raised in the Prevention of Future Deaths notice.”

    Source location

    Response from MHCLG
    Page 1 · response
    Published 9 August 2024

    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

    Peabody sought the Council’s assistance because it understood the Council or CRT/CIC held responsibility for the barrier and Dock Wall.

    Verbatim wording from the response

    “(iii) The walls bounding the water along this part of the Basin had been leased to the Council and the Council was required to keep all of the walls, without any division of particular parts, in good repair. We understand that this suggests ownership of those walls was retained by CIC under the 2015 Transfer.”

    Source location

    Response from Peabody Trust
    Page 3 · response
    Published 9 August 2024

    Open published response

  2. Central and South East Kent

    AI-generated summary

    Christopher Thomas INNES · 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

    Christopher Innes died on 25 May 2018 after being struck by a van while crossing the A28 Ashford Road in Chartham, having alighted from a bus. The concerns included the unmarked bus stop, the lack of a footway or nearby pedestrian crossing on a 50 mph road, and vegetation restricting the space available for pedestrians. There was also no clear responsibility for managing the vegetation or land adjoining the bus stop.

    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

    Unclear responsibility for vegetation management and adjoining land ownership at the bus stop

    Wider context from the report

    “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity. (2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit. (3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway. ”

    Source location

    Christopher Thomas INNES · 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

    Work with the landowner to remove low-level vegetation along the southern verge and include the cleared section in cyclic maintenance.

    Verbatim wording from the response

    “27. Whilst the verge is not in the ownership of KCC, further investigation has indicated that a 1m may be subject to public maintenance. KCC conclude that working with the landowner that low level vegetation can be removed within the southern verge for a section from the bend west of Nickle Cottages through to a point just east of Chartham Corn Mill.”

    Source location

    2019-0124-Response-by-Kent-County-Council
    Page 5 · response
    Published 14 June 2019

    Open published response

  3. North Yorkshire (West)

    AI-generated summary

    William David McCourt · 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

    William David McCourt died at the scene after losing control of his motorcycle on running water across the A6108 road. The warning sign had fallen over, and the water hazard had reportedly remained unresolved for several months. Concerns included missing records of residents’ reports, inadequate investigation of land ownership, lack of written escalation, failure to address the hazard, and inspections not recording the water as a potential hazard.

    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

    Failure to record the basis for land-ownership conclusions

    Wider context from the report

    “2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing. ”

    Source location

    William David McCourt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to establish the relevant land occupier

    Wider context from the report

    “2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing. ”

    Source location

    William David McCourt · 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

    Give staff clearer direction to ensure more detailed records are created in future.

    Verbatim wording from the response

    “(2) It was acknowledged at the inquest that on this occasion more detailed notes should have been taken and clearer direction is now being given to staff to ensure better records exist in the future. The Maintenance Manager, in this instance, was given every indication by the representative of the Ministry of Defence that they were responsible for the land in question and hence no further enquiries were made. It appeared that the farm buildings were unoccupied at the time the flooding event occurred.”

    Source location

    2013-0383-Response-by-North-Yorkshire-County-Council
    Page 1 · response
    Published 12 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026