Recurring concern

Failure to prevent unauthorised access to operational sites

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First reported 22 Jun 2018•Latest report 25 Aug 2020

Definition

What this concern includes

Includes failures of controls dedicated to preventing, detecting or responding to unauthorised entry or occupation of operational sites, including physical access controls, security presence, site checks, detection of unauthorised occupants and action to secure the site.

Not included

Excludes authorised access, ordinary site use and security arrangements where no unauthorised-entry or occupation risk is identified.
Excludes hazards inside an operational site where access control is not the deficient condition.
Excludes public access to closed or restricted hazardous sites where the existing narrower hazardous-site access concern is the more faithful boundary.
Excludes generic staffing, communication or supervision deficiencies unless they directly impair prevention or detection of unauthorised access or occupation.

Reports: 2
Individual concerns: 2
Date range: 2018–2020
Stated actions: 7

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Canary Wharf Group PLC1

First Response Group1

London Borough of Camden1

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.

25 Aug2020
Inner North London
Concerns raised1
1. Failure to detect unauthorised occupation of operational sites
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review development properties and inspect them for unauthorised access or use.
  Stated by London Borough of CamdenStated completed
2. Action
  Obtain approval and implement a standard Site Security Scope of Service across contracts requiring contracted security.
  Stated by London Borough of CamdenStated planned
3. Action
  Require security contractors to submit weekly site-activity and sign-in/out reports to the Council’s project team.
  Stated by London Borough of CamdenStated planned
1. Action
  Work with relevant departments to assess ways of making void properties less attractive or habitable to trespassers.
  Stated by London Borough of CamdenStated in progress
Respondent positions 2
1. Position
  First Response is best placed to respond to concerns about its employees’ evidence and conduct at the site.
  Stated by London Borough of CamdenRedirects responsibility
1. Position
  Existing site security arrangements were considered suitable based on property reviews and comprehensive controls already operating at Aspen House.
  Stated by London Borough of CamdenExisting arrangements considered sufficient
AI-generated summary

Daniel Richard COLEMAN · 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

Daniel Richard Coleman, a construction site manager living at a demolition site, died in an accidental fire associated with his production of crystal meth. The report raised concerns that his occupation of the site and frequent illicit drug use went unnoticed, that site security was ineffective, that records of his presence were incomplete, and that the drug and alcohol policy had not led to any drug testing.

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 detect unauthorised occupation of operational sites
Wider context from the report
“1. I heard evidence that neither Camden managers, who I was told visited the site frequently, nor First Response security officers, who were a constant presence, had noticed that Mr Coleman was living on site. Even a neighbour had seen a light on night after night in the flat where Mr Coleman had a bed, bedding, clothes hanging on a clothes rail, CD player and other personal items. 2. I also heard that Mr Coleman had previously lived on another Camden site at Bacton Low Rise, and that this too went unnoticed. ”
Source location
Daniel Richard COLEMAN · 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
Review development properties and inspect them for unauthorised access or use.

Verbatim wording from the response
“Following the Incident, and prior to the Inquest, the Council conducted a full review of its properties earmarked for future development projects i.e. either properties that were empty or had live in guardians in place for security purposes. Inspections were carried out of those properties to check for potential unauthorised access/use and nothing was found, indicating”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 2 · response
Published 26 October 2020
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
Obtain approval and implement a standard Site Security Scope of Service across contracts requiring contracted security.

Verbatim wording from the response
“As outlined above, the Council already had in place comprehensive systems for the security arrangements at Aspen House. Nevertheless, the Council has over the last few months considered its relationship with security providers across its operations and has developed a ‘Site Security Scope of Service’ specification (“the Specification”) for use across all of its contracts that require contracted security services. The Specification sets out the Council’s expectation of the standards employed by the security contractors that it engages. Third party security companies such as First Response, will be required to adhere to the requirements outlined in the Specification at all times.”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 3 · response
Published 26 October 2020
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
Require security contractors to submit weekly site-activity and sign-in/out reports to the Council’s project team.

Verbatim wording from the response
“As part of the audit of the new Specification process outlined above, the Council will, going forward, require all security contractors to submit, on a weekly basis, a report of site activity and sign in/out logs to be sent to the Council’s named project team. This will identify if any security contractor is not fulfilling its responsibility to ensure that all visitors sign in and out of sites, and it will identify any unauthorised use of the site outside of working hours.”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 4 · response
Published 26 October 2020
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
Work with relevant departments to assess ways of making void properties less attractive or habitable to trespassers.

Verbatim wording from the response
“The Council continues to explore ways that it might be able to further discourage behaviour such as that heard in evidence as displayed by Mr Coleman. For example, the Council is working with the relevant departments to see whether it can make void properties more uninhabitable/unattractive to trespassers, for example by destroying the toilets/washing facilities once the property is empty of residents and guardians. Any decision would be subject to risk assessment and this would need to be approached on a site by site basis because some facilities such as toilets, electricity and running water would be required to facilitate the security arrangements (alarms/CCTV) and for welfare purposes.”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 3 · response
Published 26 October 2020
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
First Response is best placed to respond to concerns about its employees’ evidence and conduct at the site.

Verbatim wording from the response
“Matters 3, 4 and 5 relate in the main to the Coroner’s interpretation of the evidence given at the Inquest by First Response employees. The Council heard the evidence given to the Inquest by the First Response security guards under oath, and it makes no comment on observations about that evidence. The Council considers that Matters 3, 4 and 5 are concerns that First Response would be best placed to respond to however the Coroner’s general concern regarding the security arrangements in place are covered below.”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 2 · response
Published 26 October 2020
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
Existing site security arrangements were considered suitable based on property reviews and comprehensive controls already operating at Aspen House.

Verbatim wording from the response
“Following the Incident, and prior to the Inquest, the Council conducted a full review of its properties earmarked for future development projects i.e. either properties that were empty or had live in guardians in place for security purposes. Inspections were carried out of those properties to check for potential unauthorised access/use and nothing was found, indicating”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 2 · response
Published 26 October 2020
Open published response
22 Jun2018
Inner North London
Concerns raised1
1. Failure to secure the turnstile against unauthorised access
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Raise the turnstile base with a robust plywood ramp, reducing the access gap from 30cm to 20cm.
  Stated by Canary Wharf Contractors LtdStated completed
2. Action
  Install temporary solid panels inside turnstile pods at the end of each day shift to prevent out-of-hours unauthorised access.
  Stated by Canary Wharf Contractors LtdStated completed
3. Action
  Adopt comparable turnstile security measures on future projects where access is directly from public areas.
  Stated by Canary Wharf Contractors LtdStated planned
Respondent positions 2
1. Position
  The turnstile gap was reduced by 10 centimetres, not 5 centimetres, following Samuel’s death.
  Stated by Canary Wharf Contractors LtdDisputes the concern
1. Position
  The reduced turnstile gap was considered a sufficient control measure, and the inspector required no further action.
  Stated by Canary Wharf Contractors LtdExisting arrangements considered sufficient
AI-generated summary

Samuel Patrick CLARKE · 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

Samuel Patrick Clarke, aged 19, accessed a construction site in the early hours of New Year’s Day 2018 and fell from height. He was not found until 2 January 2018 and had died from postural asphyxia following the fall and traumatic injury, with ethanol intoxication also recorded. Concerns included continued unauthorised access through a turnstile, the absence of a company contingency plan to support searches for intruders, and the adequacy of security officers’ torches.

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 secure the turnstile against unauthorised access
Wider context from the report
“1. I was told by the senior construction manager of Canary Wharf Contractors Limited that the gap under the turnstile where Samuel accessed the site has been reduced by 5cms since his death, from 30cms to 25cms, by adding a strip of plywood to the bottom. I am concerned that the turnstile is still accessible to unauthorised personnel – including to children. I heard at inquest that there are 800 tradespeople on site and I wonder whether one of them has the skills to make the turnstile secure? ”
Source location
Samuel Patrick CLARKE · 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
Raise the turnstile base with a robust plywood ramp, reducing the access gap from 30cm to 20cm.

Verbatim wording from the response
“During the inquest it was stated that the gap under the turnstile where Samuel accessed the site had been reduced by 5cm (from 30cm to 25cm) following his death. This was an incorrect estimate as the gap in fact been reduced by 10cm (from 30cm to 20cm) by the introduction of a robust plywood ramp spanning the entire base of the turnstiles so as to raise the ground level. The photo 1 below showing the reduction in gap was sent to the HSE Inspector ████████ as a sufficient control measure to prevent similar unauthorised access. The inspector confirmed receipt and required no further action.”

Source location
2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
Page 3 · response
Published 9 July 2018
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
Install temporary solid panels inside turnstile pods at the end of each day shift to prevent out-of-hours unauthorised access.

Verbatim wording from the response
“The turnstiles are located within an area where CCTV is in operation. During normal working hours the entrance is used by the entire workforce to enter and exit the project, monitored by the construction security office which is situated adjacent to the turnstiles. Following concerns raised at the inquest, a further review of the turnstile was undertaken. As a result, at the end of each day shift, temporary solid panels are installed to the inside face of the turnstile pods aimed at preventing any unauthorised out of hours access to the site via this route. See photo 2 below. This issue does not affect any other existing projects but on future projects where access to site is via a turnstile direct from public realm, similar security measures will be adopted.”

Source location
2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
Page 3 · response
Published 9 July 2018
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
Adopt comparable turnstile security measures on future projects where access is directly from public areas.

Verbatim wording from the response
“The turnstiles are located within an area where CCTV is in operation. During normal working hours the entrance is used by the entire workforce to enter and exit the project, monitored by the construction security office which is situated adjacent to the turnstiles. Following concerns raised at the inquest, a further review of the turnstile was undertaken. As a result, at the end of each day shift, temporary solid panels are installed to the inside face of the turnstile pods aimed at preventing any unauthorised out of hours access to the site via this route. See photo 2 below. This issue does not affect any other existing projects but on future projects where access to site is via a turnstile direct from public realm, similar security measures will be adopted.”

Source location
2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
Page 3 · response
Published 9 July 2018
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
The turnstile gap was reduced by 10 centimetres, not 5 centimetres, following Samuel’s death.

Verbatim wording from the response
“During the inquest it was stated that the gap under the turnstile where Samuel accessed the site had been reduced by 5cm (from 30cm to 25cm) following his death. This was an incorrect estimate as the gap in fact been reduced by 10cm (from 30cm to 20cm) by the introduction of a robust plywood ramp spanning the entire base of the turnstiles so as to raise the ground level. The photo 1 below showing the reduction in gap was sent to the HSE Inspector ████████ as a sufficient control measure to prevent similar unauthorised access. The inspector confirmed receipt and required no further action.”

Source location
2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
Page 3 · response
Published 9 July 2018
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
The reduced turnstile gap was considered a sufficient control measure, and the inspector required no further action.

Verbatim wording from the response
“During the inquest it was stated that the gap under the turnstile where Samuel accessed the site had been reduced by 5cm (from 30cm to 25cm) following his death. This was an incorrect estimate as the gap in fact been reduced by 10cm (from 30cm to 20cm) by the introduction of a robust plywood ramp spanning the entire base of the turnstiles so as to raise the ground level. The photo 1 below showing the reduction in gap was sent to the HSE Inspector ████████ as a sufficient control measure to prevent similar unauthorised access. The inspector confirmed receipt and required no further action.”

Source location
2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
Page 3 · response
Published 9 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to detect unauthorised occupation of operational sites

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to secure the turnstile against unauthorised access

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 4

Respondent positions 2

Actions described in response 3

Respondent positions 2