10 Nov 2022 Samuel Robert Pearson · Prevention of Future Deaths report South London
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Concerns raised 4 Failure of authorities to maintain partnership working during emergency decants View source Failure of authorities to share information during emergency decants View source Delays in screening referrals by the ADAPT service View source Failure to inform referrers when referral services cannot meet usual service expectations View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Review alternative accommodation and assessment processes, including how interagency working can be embedded to improve future provision.
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AI-generated summary
Samuel Robert Pearson · 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 Robert Pearson had complex mental and physical needs and was moved to temporary accommodation after a van crashed into his home. The inquest narrative stated that the accident and accommodation increased his anxiety, and that he accidentally died after taking an overdose and alcohol on 6 July 2021. Concerns included inadequate multi-agency working and information sharing during the emergency move, and a referral-screening backlog that was not communicated to his GP.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of authorities to maintain partnership working during emergency decants
Wider context from the report “(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of authorities to share information during emergency decants
Wider context from the report “(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in screening referrals by the ADAPT service
Wider context from the report “(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to inform referrers when referral services cannot meet usual service expectations
Wider context from the report “(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues . A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations .
” Open source report
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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 alternative accommodation and assessment processes, including how interagency working can be embedded to improve future provision.
Verbatim wording from the response “Review
Since the inquest CHG have been reviewing its alternative accommodation and related assessment process to see what more if anything can reasonably be done to improve the system.” Source location Response from Clarion Housing Group
Open published response
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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 At the time of the emergency relocation, direct assessment did not indicate that immediate involvement of another agency was needed.
Verbatim wording from the response “This notwithstanding CHG instigated an urgent assessment of need with Samuel and his mum and through a separate and specialist property search agency, located properties capable of meeting his needs, which was primarily for wheelchair access.
At the time of the accident CHG assessed Samuel’s needs with his mum and were not given to think (having asked a direct question) that any other agency or professional needed to be immediately involved at that stage, noting that as part of the process CHG keep matters under close review.” Source location Response from Clarion Housing Group
Open published response
29 Oct 2021 Lorraine KARAT · Prevention of Future Deaths report Inner North London
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Concerns raised 6 Lack of balcony containment View source Failure to check unauthorised balcony access View source Lack of risk assessment of flat and balcony access View source Lack of warning sign at balcony window View source Lack of window barriers or restrictors preventing balcony access View source Failure to inform occupants that balcony use is unauthorised View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Inform tenants that unauthorised flat-roof access is unsafe and not permitted.
View source
Action
Deploy additional controls at flat roofs posing significant unauthorised-access risks.
View source
Action
Issue staff guidance requiring identification of potentially accessible flat roofs and engagement with the safety team.
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AI-generated summary
Lorraine KARAT · 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
Lorraine Karat, aged 68, died after falling from a second-floor balcony outside her flat, possibly while asleep, following heavy drinking. The balcony had a low parapet and no railing, and access from the flat was not restricted by bars or window restrictors. Concerns included the absence of a risk assessment, warnings about unauthorised balcony use, and measures to prevent access to the balcony.
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. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of balcony containment
Wider context from the report “3. The balcony was not contained by a railing or other structure to make it safe for use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to check unauthorised balcony access
Wider context from the report “2. I was told by Clarion’s group health, safety and wellbeing manager at inquest, that the building manager did not know that there had been any unauthorised use of the balcony. However, the manager did not enter the flat to check , nor was there any evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of flat and balcony access
Wider context from the report “1. No evidence was provided at inquest of a risk assessment having been undertaken of Ms Karat’s flat , most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of warning sign at balcony window
Wider context from the report “4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of window barriers or restrictors preventing balcony access
Wider context from the report “4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to inform occupants that balcony use is unauthorised
Wider context from the report “2. I was told by Clarion’s group health, safety and wellbeing manager at inquest, that the building manager did not know that there had been any unauthorised use of the balcony. However, the manager did not enter the flat to check, nor was there any evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy.
” Open source report
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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 Inform tenants that unauthorised flat-roof access is unsafe and not permitted.
Verbatim wording from the response “To try and avoid the possibility of a similar situation arising at any other facility CHG are running a process to inform tenants that where the flat roof to which access might be possible this is neither authorised nor a safe activity.” Source location 2021-0364-Response-from-Clarion-Housing-Group
Open published response
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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 Deploy additional controls at flat roofs posing significant unauthorised-access risks.
Verbatim wording from the response “4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony.
Response:
As noted in the action plan additional controls are now being deployed where flat roofs have been identified as posing a significant risk of access from a tenanted property.” Source location 2021-0364-Response-from-Clarion-Housing-Group
Open published response
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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 Issue staff guidance requiring identification of potentially accessible flat roofs and engagement with the safety team.
Verbatim wording from the response “To ensure that staff are aware of the risks arising from unauthorised flat roof access CHG are issuing guidance to staff as shown in the attached “Dangers of flat roofs - Guidance for staff”.” Source location 2021-0364-Response-from-Clarion-Housing-Group
Open published response
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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 Private flats cannot be entered randomly to check balcony access, absent specific information reaching CHG.
Verbatim wording from the response “Response:
Where Ms Karat lived the flats are the tenants’ private property. There is no right for CHG to enter a flat on a random basis to check if tenants might be accessing a balcony and absent specific information reaching CHG there would be no reason to ask a tenant if they were accessing a flat roof.” Source location 2021-0364-Response-from-Clarion-Housing-Group
Open published response
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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 flat roof was not intended for access, so railings were unnecessary for its intended use.
Verbatim wording from the response “3. The balcony was not contained by a railing or other structure to make it safe to use.
Response:
CHG did not intend the flat roof to be accessed and used by anyone and were unaware that Ms Karat was accessing it. If it had been the intention of CHG that the tenant was allowed to access the flat roof, then appropriate measures would have been taken to provide railings in compliance with Building Regulations.” Source location 2021-0364-Response-from-Clarion-Housing-Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations