30 Jan 2025 James Collier SIDDONS · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Delegation of investigations without terms of reference View source Investigation conclusions based on assumptions View source Lack of detailed organisational investigation guidance View source Failure to explore all relevant investigation scenarios View source Lack of routine investigation training for managers View source Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known View source Failure of senior management involvement in investigations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Collier SIDDONS · 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
James Collier Siddons, who had very severe frailty and multiple co-morbidities, was admitted to hospital after sustaining a fractured left humerus at a nursing home. He subsequently developed aspiration pneumonia and pyelonephritis and died suddenly from sepsis on 31 January 2022. Concerns were raised that the investigation into his fracture was flawed, that the organisation lacked detailed investigation guidance and routine training, and that relevant issues were not communicated promptly by the local authority.
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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 London Borough of Bromley; that does not assign responsibility.
PFD Monitor interpretation Delegation of investigations without terms of reference
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Investigation conclusions based on assumptions
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed organisational investigation guidance
Wider context from the report “2. Mills have a policy setting out a broad overview of the principles of investigation but no detailed guidance on how an investigation should be conducted within its organisation
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Failure to explore all relevant investigation scenarios
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Lack of routine investigation training for managers
Wider context from the report “3. There is no routine investigation training for managers
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known
Wider context from the report “4. Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly but had to be conducted without Mills being satisfied that all the relevant issues were known
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Failure of senior management involvement in investigations
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Launch a Prevention and Intervention Service with a dedicated Safeguarding Hub to manage safeguarding referrals, initial information gathering and immediate safety actions.
Verbatim wording from the response “On an organisational level, there is nothing to suggest that delays in sharing PLE forms are a wider concern, and this appears to be an isolated incident. That said, LBB is committed to continuous learning and system enhancement. On April 14, 2025, we will launch our Prevention and Intervention Service, which includes a Safeguarding Hub. This Hub, staffed by dedicated and experienced practitioners, will respond to safeguarding referrals and determine whether a Section 42 Safeguarding Enquiry as outlined by the Care Act 2014 is required. The Safeguarding Hub will manage all initial information gathering and take immediate action to ensure the person's safety, working closely with both statutory and non-statutory partners, as well as the individual and/or their representative.” Source location Response from London Borough of Bromley
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 Review the contents of the Provider Lead Enquiry form.
Verbatim wording from the response “The Local Authority are also going to embark on a review of the contents of the PLE form.” Source location Response from London Borough of Bromley
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 Delays in sharing Provider Lead Enquiry forms are not a wider concern and the incident appears isolated.
Verbatim wording from the response “On an organisational level, there is nothing to suggest that delays in sharing PLE forms are a wider concern, and this appears to be an isolated incident. That said, LBB is committed to continuous learning and system enhancement. On April 14, 2025, we will launch our Prevention and Intervention Service, which includes a Safeguarding Hub. This Hub, staffed by dedicated and experienced practitioners, will respond to safeguarding referrals and determine whether a Section 42 Safeguarding Enquiry as outlined by the Care Act 2014 is required. The Safeguarding Hub will manage all initial information gathering and take immediate action to ensure the person's safety, working closely with both statutory and non-statutory partners, as well as the individual and/or their representative.” Source location Response from London Borough of Bromley
Open published response
10 Nov 2022 Samuel Robert Pearson · Prevention of Future Deaths report South London
View report summary
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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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 Bromley; 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 London Borough of Bromley; 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 London Borough of Bromley; 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 London Borough of Bromley; 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 Request a meeting with Bromley Federation of Housing Associations members to discuss notifying the Local Authority about relevant emergency decants.
Verbatim wording from the response “3. Additionally, senior management in the LA Housing department have contacted Bromley Federation of Housing Associations to request that a meeting is convened to discuss this topic with their members, to ensure that they have due regard to arrangements for notifying LBB of emergency decants where there is a vulnerable household member.” Source location Response London Borough of Bromley Council
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 Notify relevant Local Authority personnel promptly when future emergency decants involve vulnerable people receiving social care support.
Verbatim wording from the response “1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.” Source location Response London Borough of Bromley Council
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 Provide Clarion with contact details for vulnerable adults’ services, children’s services and Local Authority housing contacts for emergency-decant notifications.
Verbatim wording from the response “2. In respect of London Borough of Bromley’s largest provider Clarion, Senior Management in the Housing Department (LA) made contact with a Clarion Manager on the 14/12/22 and 29/12/22, raising the need to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Clarion have been asked to set out a notification protocol within this policy so that this can be agreed with the Local Authority. It is appropriate for the Housing Association to do this as they know their processes best. The Local Authority have already provided contact details to Clarion for vulnerable adults and children’s services as well as an LA housing contact, so that emergency decants can be notified as soon as the need is identified.” Source location Response London Borough of Bromley Council
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 Housing associations are responsible for handling emergency decants and developing notification protocols because they know their processes best.
Verbatim wording from the response “1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.” Source location Response London Borough of Bromley Council
Open published response
21 Oct 2013 Elsie Gibson · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Failure to maintain contemporaneous records of inspections View source Failure to take enforcement action against persons erecting scaffold towers without a licence View source Delays in investigating reported incidents involving unlicensed scaffold towers View source
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.
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AI-generated summary
Elsie Gibson · 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
Elsie Gibson, aged 94, slipped from a narrowed pavement while passing an unlicensed scaffold tower in High Street, Bromley, on 4 January 2013. She sustained a fractured hip and died in hospital on 9 January 2013. The concerns included the erection of the scaffold without required formalities and the apparent lack of prompt investigation or enforcement action by the Council after the incident.
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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 London Borough of Bromley; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous records of inspections
Wider context from the report “Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities.
When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest.
I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place . I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated.
As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured.
I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities.
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Failure to take enforcement action against persons erecting scaffold towers without a licence
Wider context from the report “Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities.
When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest.
I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated .
As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured.
I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action . If action is taken, and publicity given, it may lead others to adhere to the necessary formalities.
” 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 Bromley; that does not assign responsibility.
PFD Monitor interpretation Delays in investigating reported incidents involving unlicensed scaffold towers
Wider context from the report “Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities.
When the incident was reported to the Council by the son, it does not appear to have been investigated promptly . I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest.
I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated.
As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured.
I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations