4 Mar 2024 Sandra Elizabeth SENIOR · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure of the front entrance access-control system to secure and permit controlled entry View source Failure to secure the secondary access barrier against unauthorised entry View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sandra Elizabeth SENIOR · 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
Sandra Senior travelled to central London on 24 September 2023 and gained access to Tavistock Chambers, where she completed suicide. The report raised concerns that the building’s access-control and safety systems were not operating or being used effectively, allowing unauthorised access, and noted that this was the second similar death there within approximately 18 months.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure of the front entrance access-control system to secure and permit controlled entry
Wider context from the report “The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times” . The witness confirmed that the front entrance was hooked open at the material time ; this was confirmed by photographic evidence provided by the Metropolitan Police Service.
There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.”
It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time .
The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to secure the secondary access barrier against unauthorised entry
Wider context from the report “The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service.
There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut . A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.”
It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time .
The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace.
” 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 Maintain a specific contract for repairing communal door-entry systems when faults occur.
Verbatim wording from the response “On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.” Source location Response from Camden 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 Remove the communal entrance door’s latch and hook to prevent it being held open.
Verbatim wording from the response “On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.” Source location Response from Camden 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 Inspection frequency cannot be increased because the caretaking service’s frequency is determined by available resources.
Verbatim wording from the response “The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service.” Source location Response from Camden Council
Open published response
25 Aug 2020 Daniel Richard COLEMAN · Prevention of Future Deaths report Inner North London
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Concerns raised 6 Failure to detect drug or alcohol impairment View source Failure to detect unauthorised occupation of operational sites View source Failure to assess drug-related risk for personnel in charge of an entire site View source Failure to implement drug testing under the drug and alcohol policy View source Incomplete site signing in and out records View source Failure to provide effective security patrols View source See 3 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
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.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to detect drug or alcohol impairment
Wider context from the report “7. I heard evidence that not one of Mr Coleman’s Camden managers or First Response colleagues noticed that he was in any way intoxicated or under the influence of drugs .
” 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 Camden; that does not assign responsibility.
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 .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug-related risk for personnel in charge of an entire site
Wider context from the report “8. Evidence was given that Camden did not regard Mr Coleman’s occupation as high risk for drugs because he did not operate heavy machinery, but he was in charge of a whole site .
The explosion and fire he started accidentally could have resulted in other fatalities as well as his own.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to implement drug testing under the drug and alcohol policy
Wider context from the report “9. I was told that a Camden drug and alcohol policy that had been in place for five months at the time of Mr Coleman’s death had not resulted in a single attempt at a drug test .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Incomplete site signing in and out records
Wider context from the report “6. The Camden Council signing in/out record was incomplete, often not recording Mr Coleman’s presence on site at all , and the last entry before Mr Coleman died on 14 February 2020 was dated 7 February 2020.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective security patrols
Wider context from the report “3. The evidence from the two First Response night time security officers who came to court was inconsistent and concerning.
One said that he always patrolled twice an hour. The other said that each officer patrolled once every two hours.
When I asked one officer what he did in between patrols (I was keen to exclude the possibility of security officers sleeping through the night), he said that it took him five minutes to write up each patrol, then he just sat and waited for the next patrol. The writing up he described was one line only, exactly the same line recorded with the time advanced by one hour as on the previous line. This would have taken a matter of seconds.
One officer gave evidence that he photographed the building during every one of his patrols.
It later emerged that this protocol of photographing was only introduced after 14 February 2020, though I had specifically asked about the situation before Mr Coleman’s death. I was misled.
This does not paint a picture of effective security.
” 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 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
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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 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
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 Revise the Substance Misuse Policy for legal compliance and alignment with current best practice.
Verbatim wording from the response “Her Majesty’s Coroner was provided with a copy of the Council’s Substance Misuse Policy (“the Policy”). The Policy was in its infancy at the time of Mr Coleman’s incident and at the time of the Inquest it was undergoing consultation and review.” Source location 2020-0166-Response-from-Camden-Council_Redacted.pdf
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 Roll out the updated employee drug-testing regime.
Verbatim wording from the response “Trade Unions are currently being consulted on the Policy and it is hoped that formal consultation will be complete before the end of the year, with the testing regime to be rolled out in the new year.” Source location 2020-0166-Response-from-Camden-Council_Redacted.pdf
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 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
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 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
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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 Construction Manager roles are not safety-critical for drug testing and will remain outside that definition in line with industry standards.
Verbatim wording from the response “Her Majesty’s Coroner may recall from the evidence at the Inquest that some employment roles are identified as safety critical for drug testing under the Policy, such as those who” Source location 2020-0166-Response-from-Camden-Council_Redacted.pdf
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 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
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 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
Open published response
29 Jan 2020 Thiago Araujo · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of support or education for families and carers managing emotionally unstable personality disorder View source Failure to make arrangements to address risks when closing crisis team referrals View source Lack of a process for families to escalate concerns to prevent delivery of hazardous packages View source Failure to inform families about the facility for reopening crisis team support View source Delays of 14 days in securing mental health act assessments View source Failure to act on an inpatient admission plan following identification of acute suicide risk 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.
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AI-generated summary
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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 Camden; that does not assign responsibility.
PFD Monitor interpretation Lack of support or education for families and carers managing emotionally unstable personality disorder
Wider context from the report “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to make arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for families to escalate concerns to prevent delivery of hazardous packages
Wider context from the report “6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to inform families about the facility for reopening crisis team support
Wider context from the report “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support . Mr Araujo’s family were unaware of this facility .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Delays of 14 days in securing mental health act assessments
Wider context from the report “5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks . Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to act on an inpatient admission plan following identification of acute suicide risk
Wider context from the report “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care . No actions were taken to affect this plan .
” Open source report
28 Mar 2019 Tony Goodridge · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Obstructed emergency access to the property by parked vehicles View source Lack of a smoke alarm in the property 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
Tony Goodridge · 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
Tony Goodridge died after being found unresponsive in his flat following a fire on 19 November 2018; the medical cause was recorded as inhalation of fire fumes and airway burns. The principal concerns were that there was no smoke alarm in the property and that parked vehicles made it more difficult for the London Fire Brigade to reach the property.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Obstructed emergency access to the property by parked vehicles
Wider context from the report “(2) The London Fire Brigade had some difficulty reaching the property due to parked vehicles in the vicinity .
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Lack of a smoke alarm in the property
Wider context from the report “(1) Mr Goodridge did not have a smoke alarm in his property .
” Open source report
20 Aug 2018 Jacob Sulaiman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to record and share relevant information about contacts with other services and their outcomes View source Lack of written records of response-officer visits in the property View source Inaccessibility of information about recent contacts with other services during emergency call-outs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacob Sulaiman · 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
Jacob Sulaiman died at home on 8 December 2017 after a fire started in his bedroom, causing carbon monoxide poisoning. The principal concerns were that response officers did not have complete or readily accessible information about his contacts with other services, including the outcome of a paramedic visit, which may have affected the assessment and management of his mental capacity.
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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure to record and share relevant information about contacts with other services and their outcomes
Wider context from the report “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Lack of written records of response-officer visits in the property
Wider context from the report “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of information about recent contacts with other services during emergency call-outs
Wider context from the report “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
” 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 Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
Verbatim wording from the response “This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Caroline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.” Source location 2018-0252-Response-by-London-Borough-of-Camden
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 Develop information-sharing arrangements with London Ambulance Service.
Verbatim wording from the response “The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Caroline service has already made contact with LAS to begin discussions about how information could be better shared in future.” Source location 2018-0252-Response-by-London-Borough-of-Camden
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 Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
Verbatim wording from the response “In preparation for this move, a new IT platform was required to support the” Source location 2018-0252-Response-by-London-Borough-of-Camden
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 Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
Verbatim wording from the response “Wellbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.” Source location 2018-0252-Response-by-London-Borough-of-Camden
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 Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
Verbatim wording from the response “It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Wellbeing were aware of, and coordinated the responses, whether they were remotely or in person.” Source location 2018-0252-Response-by-London-Borough-of-Camden
Open published response
12 Dec 2016 Ellen Eileen Margaret Kelly · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Lack of proper self-closing mechanisms on flat front doors View source Failure of flat front doors to provide 30-minute fire resistance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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. 3
Action
Complete fire safety works across 4,500 high-priority housing properties, including fire doors, signage, emergency lighting, fire stopping and surface-spread measures.
Stated completedThe respondent said that this action was complete when they made their response on 12 February 2017. View source
Action
Deliver the 2017/18 fire-safety programme in higher-risk properties, including flat and communal door upgrades, alarms, emergency lighting and compartmentation.
Stated plannedThe respondent said that this action was planned when they made their response on 12 February 2017. View source
Action
Install FD30S flat entrance doors with closers, renew communal intake doors and redecorate Kilburn Gate communal areas to Class 0 fire-resistant standard.
Stated plannedThe respondent said that this action was planned when they made their response on 12 February 2017. View source
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AI-generated summary
Ellen Eileen Margaret Kelly · 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
Ellen Eileen Margaret Kelly suffered smoke inhalation injuries in a flat fire on 7 July 2016 after a cigarette was not fully extinguished, and died at St Marys Hospital, Paddington, on 16 July 2016. The substantive concerns were that the flat’s front door lacked a self-closing mechanism and that other doors in the block did not meet the 30-minute fire-resistance standard, potentially allowing fire and smoke to spread more quickly.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Lack of proper self-closing mechanisms on flat front doors
Wider context from the report “Evidence was given by Watch Manager ████████ from the London Fire Brigade that:
1. ████████ is a block owned by London Borough of Camden.
2. At the time of the fire, the front door of Flat 13 was left open whilst the occupant went to raise the alarm. This caused the fire to spread more quickly than would have been the case had the door been shut. It also caused smoke to disperse in the common parts of the building.
3. Another family was trapped in Flat 15 (above Flat 13) until the London Fire Brigade attended.
4. The front door of Flat 13 should have been fitted with a self-closing mechanism but was not.
5. Other front doors in the block identified by the London Fire Brigade when they attended were not of a suitable standard in that they did not comply with the 30 minute fire resistant British Standard.
I consider that it is likely that there are front doors of flats within Kilburn Gate which do not have:
a. A proper self-closing mechanism in accordance with legal requirements as this was the case with the door to Flat 13, and
b. Do not comply with the relevant British Standard, in that they are not fire resistant for 30 minutes or more.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure of flat front doors to provide 30-minute fire resistance
Wider context from the report “Evidence was given by Watch Manager ████████ from the London Fire Brigade that:
1. ████████ is a block owned by London Borough of Camden.
2. At the time of the fire, the front door of Flat 13 was left open whilst the occupant went to raise the alarm. This caused the fire to spread more quickly than would have been the case had the door been shut. It also caused smoke to disperse in the common parts of the building.
3. Another family was trapped in Flat 15 (above Flat 13) until the London Fire Brigade attended.
4. The front door of Flat 13 should have been fitted with a self-closing mechanism but was not.
5. Other front doors in the block identified by the London Fire Brigade when they attended were not of a suitable standard in that they did not comply with the 30 minute fire resistant British Standard.
I consider that it is likely that there are front doors of flats within Kilburn Gate which do not have:
a. A proper self-closing mechanism in accordance with legal requirements as this was the case with the door to Flat 13, and
b. Do not comply with the relevant British Standard, in that they are not fire resistant for 30 minutes or more.
” 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 Complete fire safety works across 4,500 high-priority housing properties, including fire doors, signage, emergency lighting, fire stopping and surface-spread measures.
Verbatim wording from the response “The London Borough of Camden takes its responsibilities for fire safety in its Housing stock very seriously and will take action to address the concerns that have been raised. The Council already has a significant programme in place to improve fire safety in council housing. We hold regular meetings with the Fire Service to review safety and risk assessments and a £5m programme of fire safety works to 4,500 high priority housing properties has already been completed. The scope of the works is comprehensive and includes renewal or upgrading flat entrance doors to “FD30s” standard, signage, emergency lighting installations and fire stopping. The work also includes review and attention to surface spread of flame in means of escape provision.” Source location 2016-0451-Response-by-London-Borough-of-Camden
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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 Deliver the 2017/18 fire-safety programme in higher-risk properties, including flat and communal door upgrades, alarms, emergency lighting and compartmentation.
Verbatim wording from the response “The council employs specialists to assist in specification and delivery of the programme and has appointed a fire safety advisor (recruited from the London Fire Service) to help assess risk and advise on fire protection. For 2017/18, the projected spend on fire safety is over £10m and is again concentrated on higher risk properties. The works include upgrading or renewing flat entrance doors to FD30S standard, renewal or upgrading of communal doors, installing fire alarm system to street properties, installing emergency lighting and fire stopping (compartmentation). In addition, the council’s Better Homes (building fabric and communal repairs) programme will incorporate fire safety works on each block where work is undertaken.” Source location 2016-0451-Response-by-London-Borough-of-Camden
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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 Install FD30S flat entrance doors with closers, renew communal intake doors and redecorate Kilburn Gate communal areas to Class 0 fire-resistant standard.
Verbatim wording from the response “In regards to Kilburn Gate, fire safety works have been prioritised and have been tendered. This work includes installing new FD30s flat entrance doors incorporating door closers, renewal of communal intake doors and redecoration of communal areas to Class 0 fire resistant standard. We are currently consulting with Leaseholders in the block (as required by section 20 of the Landlord and Tenant Act 1985) and this consultation is due to be completed in mid-February and the works are expected to commence in March 2017.” Source location 2016-0451-Response-by-London-Borough-of-Camden
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14 Apr 2014 Francis Nelson GOLDING · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Particular vulnerability of cyclists at the junction View source Insufficient space for cycles in the oncoming bus lane View source
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
Francis Nelson GOLDING · 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
Francis Nelson Golding, aged 59, died after the pedal cycle he was riding collided with a left-turning coach at the junction of Vernon Place and Southampton Row in London. The inquest heard that three cyclists had died at the junction in the previous ten years in collisions with left-turning vehicles, and raised concerns that the junction left cyclists particularly vulnerable, including because of the oncoming bus lane. Early consideration of improvements to the junction was requested.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Particular vulnerability of cyclists at the junction
Wider context from the report “During the course of the inquest, I heard evidence of three fatalities at this junction in the last ten years, each involving a cyclist colliding with a left turning vehicle.
Whilst of course every road user has a responsibility to take care at junctions, it does seem that this junction leaves cyclists particularly vulnerable . There is also, I heard, an issue with the oncoming bus lane not leaving any additional space for cycles.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Insufficient space for cycles in the oncoming bus lane
Wider context from the report “During the course of the inquest, I heard evidence of three fatalities at this junction in the last ten years, each involving a cyclist colliding with a left turning vehicle.
Whilst of course every road user has a responsibility to take care at junctions, it does seem that this junction leaves cyclists particularly vulnerable. There is also, I heard, an issue with the oncoming bus lane not leaving any additional space for cycles .
” 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 Commission traffic consultants to model signals across the Holborn area scheme, including Vernon Place and Southampton Row, and assess options for improving cyclist facilities.
Verbatim wording from the response “A brief will be issued to traffic consultants by the end of May 2014 to invite tenders for the next stage of development. Consultants will be commissioned to undertake traffic signal modelling for the whole Holborn area based scheme area, which includes the Southampton Row/Vernon Place junction. Under the current programme it is anticipated that consultants will be appointed in mid June 2014. A range of options will be considered as part of this commission which will explore possibilities to significantly improve facilities for cyclists. This stage of the process is expected to take 9 months.” Source location 2014-0136-Response-by-Camden-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permit cyclists to use the Bloomsbury Way contra-flow bus lane with bollards, signing and a clear box junction under an experimental order.
Verbatim wording from the response “Where it is possible for Camden to implement changes we do so. One of the most recent examples, which is also referred to in the report, is allowing cyclists to use the contra-flow bus lane on Bloomsbury Way. When the bus priority scheme was first implemented, in 2009, cyclists were not permitted to use the contra-flow bus lane as, due to lack of road space and issues with junction capacity, the bus lane could not be widened to safely accommodate cyclists passing buses. This resulted in cyclists travelling west having to use the Holborn gyratory via Drake Street, Proctor Street and High Holborn to re-join the corridor at New Oxford Street, which has been raised as a concern by cyclists.” Source location 2014-0136-Response-by-Camden-Council
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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 Implementation of major junction changes cannot occur immediately because it depends on consultation, funding and coordination with other projects.
Verbatim wording from the response “A brief will be issued to traffic consultants by the end of May 2014 to invite tenders for the next stage of development. Consultants will be commissioned to undertake traffic signal modelling for the whole Holborn area based scheme area, which includes the Southampton Row/Vernon Place junction. Under the current programme it is anticipated that consultants will be appointed in mid June 2014. A range of options will be considered as part of this commission which will explore possibilities to significantly improve facilities for cyclists. This stage of the process is expected to take 9 months.” Source location 2014-0136-Response-by-Camden-Council
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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 Collision data shows no consistent pattern at the junction requiring targeted safety action based on the reported cyclist vulnerability.
Verbatim wording from the response “Collision statistics
As part of Camden’s approach to improving road safety, officers undertake a robust analysis of casualty data for the whole borough, to identify those locations (corridors and neighbourhoods) with the highest number of KSI (killed and seriously injured) over the most recent three year period. This analysis includes looking at a level of detail that will enable officers to identify patterns or common issues, such as being a ‘left hook’ issue or all collisions occurring at a particular time of day (light or dark). This is the standard industry approach and is considered a sufficient period of time to pick up trends and identify areas of concern, not least to reflect that as traffic and vehicle movement patterns change over time, situations can be very different from longer periods ago.” Source location 2014-0136-Response-by-Camden-Council
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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 Significant signal changes require Transport for London’s agreement and implementation, and it can veto highway works affecting the strategic road network.
Verbatim wording from the response “The road network in Camden is large and complex with a number of different demands and it is necessary for Camden to take a strategic view of that network when implementing change and developing proposals. Implementing changes to any signal junction on the central London network impacts upon the wider area, and the result is that no significant change at any one location can or should be considered in isolation. Furthermore, the introduction of such changes is not solely within the control of Camden as it would require working closely with and approval from TfL, particularly in relation to what the wider impacts would be. I explain the wider roles of each authority below.” Source location 2014-0136-Response-by-Camden-Council
Open published response
28 Mar 2014 Dr Rosemary Simpson · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Hazard from pedestrians crossing on flashing lights amid busy pedestrian and vehicular traffic View source Failure of bus stop siting to provide adequate bus visibility and short crossing distances 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
Dr Rosemary Simpson · 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
Dr Rosemary Simpson was struck by a double-decker bus while crossing Tottenham Court Road at a running pace as the lights changed to flashing amber. The concerns identified were heavy pedestrian and vehicle traffic, pedestrians crossing on flashing lights, and reduced bus visibility caused by the position of the bus stop, which required some routes to cross three lanes.
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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 Camden; that does not assign responsibility.
PFD Monitor interpretation Hazard from pedestrians crossing on flashing lights amid busy pedestrian and vehicular traffic
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
The area is often very busy with pedestrian and vehicular traffic and pedestrians frequently cross on the flashing lights, sometimes at speed . Visibility for buses can be affected by the siting of the bus stop, so that some routes have to cross three lanes in a short distance. It is not possible to move the bus stop at the present time.
” 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 Camden; that does not assign responsibility.
PFD Monitor interpretation Failure of bus stop siting to provide adequate bus visibility and short crossing distances
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
The area is often very busy with pedestrian and vehicular traffic and pedestrians frequently cross on the flashing lights, sometimes at speed. Visibility for buses can be affected by the siting of the bus stop , so that some routes have to cross three lanes in a short distance . It is not possible to move the bus stop at the present time.
” 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