30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Stephen Allan · 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
Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.
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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Delays in police alerting of the LFB and subsequent emergency response
Wider context from the report “The process for alerting the LFB by the Metropolitan Police Service (MPS) uses a telephone to transmit information from the MPS to the LFB , rather than using a CAD-mediated system to transfer information electronically from the Police to the LFB which is faster than transmitting information by telephone . This delay means that there is a risk that future deaths could occur due to a delay in the LFB being alerted by the Police and a corresponding delay to the LFB's subsequent response to an emergency incident .
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of riverside buoyancy aids
Wider context from the report “The lighting of buoyancy aids on the riverside is not adequate , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
Buoyancy aids are more visible when painted with white stripes and/or reflective white stripes. However, not all buoyancy aids are so painted , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
” 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 Assess each water-adjacent site using watercourse, access, rescue, hazard, and incident-history risk criteria.
Verbatim wording from the response “2. Risk Assessment Criteria” Source location Response from London Borough of Barking and Dagenham
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 Implement a structured inspection and maintenance programme to maintain equipment functionality and visibility and promptly replace damaged or missing assets.
Verbatim wording from the response “4. Inspection and Maintenance Regime” Source location Response from London Borough of Barking and Dagenham
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 or upgrade buoyancy aids at high-risk locations, prioritising high-traffic areas and improving visibility with reflective markings.
Verbatim wording from the response “3. Standardisation of Safety Equipment” Source location Response from London Borough of Barking and Dagenham
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 Consider lighting buoyancy aids at sites used during evenings or affected by low visibility.
Verbatim wording from the response “• Aids will be clearly marked with reflective white stripes or similar enhancements to improve visibility in low light.” Source location Response from London Borough of Barking and Dagenham
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 Survey all Borough waterbodies and riverside locations, mapping safety assets and identifying gaps or deterioration.
Verbatim wording from the response “1. Comprehensive Survey and Asset Mapping” Source location Response from London Borough of Barking and Dagenham
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 Emergency communications between the Metropolitan Police Service and London Fire Brigade are outside the Borough’s management responsibility.
Verbatim wording from the response “While our Borough does not manage emergency communications between the Metropolitan Police Service and the London Fire Brigade, we strongly support improvements in this area. We will work with the Local Resilience Forum and relevant partners to advocate for enhanced inter-agency communication, particularly in critical response scenarios.” Source location Response from London Borough of Barking and Dagenham
Open published response
21 Dec 2018 Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 6 Failure to maintain originally provided fire safety measures, including the kitchen door View source Failure to upgrade existing maisonettes in line with fire safety best-practice guidance View source Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection View source Inadequate design of alternative means of escape from upper floors of maisonettes View source Failure to adopt relevant fire safety guidance for purpose-built blocks of flats View source Absence of functioning fire detection and warning in maisonette halls or landings View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Mihaela Lazar and Ms Dorina Zangari · 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
Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.
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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain originally provided fire safety measures, including the kitchen door
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Failure to upgrade existing maisonettes in line with fire safety best-practice guidance
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire .
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat , in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats'.
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Inadequate design of alternative means of escape from upper floors of maisonettes
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Failure to adopt relevant fire safety guidance for purpose-built blocks of flats
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat, in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats' .
” 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 London Borough of Barking and Dagenham; that does not assign responsibility.
PFD Monitor interpretation Absence of functioning fire detection and warning in maisonette halls or landings
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing , which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations