6 Nov 2024 Sarah McGreevy · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Risk of falls from residents climbing onto balconies to clear blocked drainpipes View source Failure to undertake remedial works to guttering and drainpipes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah McGreevy · 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
Sarah McGreevy, aged 37, sustained fatal injuries after falling from her sixth-floor balcony on 16 June 2024. It was found more likely than not that she had climbed onto a wooden box to clear a drainpipe and accidentally fallen. The principal concerns were residents’ practice of climbing onto balconies to clear blocked drainpipes, the associated risk of falls, and the absence of remedial works that could allow the practice to continue.
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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Risk of falls from residents climbing onto balconies to clear blocked drainpipes
Wider context from the report “(1) Several ████████ residents reported a practice of climbing onto their balconies in order to clear blocked drainpipes . This practice carries a clear risk of falls .
(2) The leaseholder of ████████ informed me that he was not aware of any work being undertaken to the guttering or drainpipes to the block following Ms McGreevy’s death.
(3) In the absence of remedial works, the practice of residents unblocking pipes themselves is likely to continue.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake remedial works to guttering and drainpipes
Wider context from the report “(1) Several ████████ residents reported a practice of climbing onto their balconies in order to clear blocked drainpipes. This practice carries a clear risk of falls.
(2) The leaseholder of ████████ informed me that he was not aware of any work being undertaken to the guttering or drainpipes to the block following Ms McGreevy’s death.
(3) In the absence of remedial works , the practice of residents unblocking pipes themselves is likely to continue.
” 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 Survey balcony surfaces and surface-water drainage across Macbeth House to identify defects and safety risks.
Verbatim wording from the response “A condition survey was undertaken from ground level on Monday, 25 November 2024 by the Borough’s Area Surveying Manager, and the TMO Manager. The survey was to examine the external elements and elevations with particular attention being given to the condition of surface water drainage serving the balconies to the rear of the block.” Source location Response from London Borough of Hackney
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 Publish balcony safety guidance in the January Love Hackney edition, including instructions to avoid steps, stools and ladders and report guttering or pipework repairs.
Verbatim wording from the response “The Borough produces a publication called ‘Love Hackney’ which is printed 10 times a year and 120,000 copies delivered to homes and businesses in each publication cycle. The magazines are also available at pick up service points across the Borough and is available on the Borough’s website. The publication provides information including articles under the title ‘Housing Info’ which is for council tenants and leaseholders. The January edition will provide a general message regarding keeping residents, families and neighbours safe in their homes and to remind occupiers that if you have a balcony not to use steps, stools or ladders on the balcony and if any repairs need to be carried out, including issues with guttering or pipe works to contact the repairs contact centre.” Source location Response from London Borough of Hackney
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 No reports or defects were identified indicating that balcony drainage required remedial works.
Verbatim wording from the response “Following receipt of the Prevention of Future Deaths Report a search was conducted on the housing repairs system to identify any reports of blockages or defects in relation to the balcony surface water drainage stack. A search was conducted in respect of the block as a whole and individual flats. No reports had been received for any Works Orders. Enquiries were further undertaken with the TMO and they have confirmed no reports of any defects or request for repairs were made. At no point are tenants / leaseholders expected to undertake repairs to, or unblocking of gutters / fall pipes.” Source location Response from London Borough of Hackney
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 Reactive repairs, established reporting routes and guidance mean residents are not expected to unblock gutters or fall pipes themselves.
Verbatim wording from the response “Following receipt of the Prevention of Future Deaths Report a search was conducted on the housing repairs system to identify any reports of blockages or defects in relation to the balcony surface water drainage stack. A search was conducted in respect of the block as a whole and individual flats. No reports had been received for any Works Orders. Enquiries were further undertaken with the TMO and they have confirmed no reports of any defects or request for repairs were made. At no point are tenants / leaseholders expected to undertake repairs to, or unblocking of gutters / fall pipes.” Source location Response from London Borough of Hackney
Open published response
6 Jun 2024 Anoush Summers · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to replace or repair reported-broken wrist alarms View source Lack of a clear allocation of duties and responsibilities for reporting wrist-alarm faults View source Failure of attending carers to escalate reported wrist-alarm faults View source Lack of training, instruction or guidance for carers on testing wrist alarms View source Failure of care workers to read care notes containing wrist-alarm information View source Lack of clear instruction on care workers’ required review of care notes 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
Anoush Summers · 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
Anoush Summers, a frail woman living alone, fell at home after her wrist alarm had been reported as broken and was found the following day. She was taken to hospital and died of hypothermia on 14 January 2024. Concerns included the failure to repair or replace the alarm, unclear reporting responsibilities, and inadequate instructions or training for carers regarding alarm faults and care notes.
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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure to replace or repair reported-broken wrist alarms
Wider context from the report “1. Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear allocation of duties and responsibilities for reporting wrist-alarm faults
Wider context from the report “6. There was no clear system identified between the company providing carers and the local authority , as to the duties and responsibilities of each in the reporting of faults with wrist alarms .
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure of attending carers to escalate reported wrist-alarm faults
Wider context from the report “3. None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority .
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Lack of training, instruction or guidance for carers on testing wrist alarms
Wider context from the report “5. None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users .
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure of care workers to read care notes containing wrist-alarm information
Wider context from the report “4. The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes . No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Lack of clear instruction on care workers’ required review of care notes
Wider context from the report “4. The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users .
” Open source report
4 Mar 2024 Vanessa FORD · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure of wall mitigation and safety measures to impede railway access View source Frequent public access to railway tracks in the Hackney Central/Dalston Kingsland vicinity View source Siting of an electrical box facilitating access to the railway wall View source Siting of street furniture facilitating access to the railway network View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Vanessa FORD · 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
On 23 September 2023, Vanessa Ford consumed a significant amount of alcohol during an acute mental health crisis, accessed the railway network and was struck by a train after dropping onto the tracks. The report raised concerns about frequent public access to the railway in the area, the effectiveness of safety measures on the wall, and street furniture making access easier and potentially undermining safety efforts.
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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure of wall mitigation and safety measures to impede railway access
Wider context from the report “(2) Evidence provided from CCTV footage and photographic evidence taken by the British Transport Police demonstrated that the particular piece of wall, which was used to access the railway network on 23 September 2023, was relatively low , despite an approximate drop onto the tracks below being 20 feet. The British Transport Police Post Incident Site Report sets out that the “Road over rail bridge has metal covers and hostile toppings on walls directly over the railway”; ████████
████████ This raises the concern that the mitigation/safety measures in place on the wall may not have been as effective as one might expect .
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Frequent public access to railway tracks in the Hackney Central/Dalston Kingsland vicinity
Wider context from the report “(1) I was provided with evidence that there have been three (non-fatal) incidents in the vicinity of the Hackney Central/Dalston Kingsland areas of the rail network in the 12 months prior to this incident on 23 September 2023 (British Transport Police Post Incident Site Report DOCU Reference: DOCU 2023 1576 refers). ████████
████████
████████ The concern here is that there is evidence to suggest that access to the railway tracks by members of the public may be a frequent issue in this 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Siting of an electrical box facilitating access to the railway wall
Wider context from the report “(3) The CCTV footage and photographic evidence presented to me, demonstrated that Ms Ford’s access to the wall, and thereby the railway network below, ████████
████████
████████. In their oral evidence during the inquest, the Officer from the British Transport Police confirmed their view, which I accepted, that this electrical box makes access to the wall much easier than it should be . They also confirmed that this issue is unlikely to be confined solely to the ████████ and that such items of street furniture may pose similar risks across the railway network.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Siting of street furniture facilitating access to the railway network
Wider context from the report “(4) In addition to the ████████ mentioned at (3) above, the evidence revealed numerous items of street furniture on the ████████
████████, all of which could be used to facilitate easier access to the wall and the railway network . The concern here is that the siting of items of street furniture generally on this bridge poses risks to all manner of members of the public , from those contemplating suicide, to young children, and may undermine safety efforts to impede easy access to the railway network .
” 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 Continue discussions between highways and planning teams to develop a planning-process mechanism for identifying and flagging electrical apparatus and street furniture near railway bridges.
Verbatim wording from the response “9. Discussions have taken place, and will continue, between the highways team and the local planning authority to see whether an effective mechanism could be put in place through the planning process to identify and flag up electrical apparatus and street furniture at locations such as this one.” Source location Response from Hackney Council
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 Remove recycling bins near Martel Place that could facilitate access to the railway network.
Verbatim wording from the response “10. In respect of the various recycling bins nearby on Martel Place, the Council has taken steps to remove those bins and this action was completed on 8 May 2024.” Source location Response from Hackney Council
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 Network Rail is responsible for further measures addressing concerns about the Martel Place access gate and railway wall.
Verbatim wording from the response “11. The Council has also been in contact with Network Rail to coordinate actions and ensure clear ownership of responsibilities. The Council has received confirmation from Network Rail that further measures to address specific concerns around the access gate at Martel Place and the wall more generally are underway.” Source location Response from Hackney Council
Open published response
27 Jun 2018 Dudley Vincent Brown · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Delays in AMHPS referral and assessment across weekends and bank holidays View source Delays in AMHPS assessment caused by unavailable property information View source Failure to arrange welfare checks pending mental health assessment View source Unclear allocation of responsibility for initiating emergency procedures under the Mental Health Act View source Incorrect understanding of referral routes to the Approved Mental Health Practitioner Service View source See 2 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
Dudley Vincent Brown · 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
Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.
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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Delays in AMHPS referral and assessment across weekends and bank holidays
Wider context from the report “(4) Mr Brown’s referral to the AMHPS and subsequent assessment was delayed due to intervening weekends (including a 3 day bank holiday weekend).
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Delays in AMHPS assessment caused by unavailable property information
Wider context from the report “(5) Mr Brown’s assessment by the AMHPS team was delayed due to the need for information regarding the nature of his property being required by the Metropolitan Police as part of their risk assessment.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange welfare checks pending mental health assessment
Wider context from the report “(2) Mr Brown’s care package was withdrawn on 27 December 2017. No arrangements were put into place for Mr Brown’s welfare to be checked in the period pending a mental health assessment.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of responsibility for initiating emergency procedures under the Mental Health Act
Wider context from the report “(1) Following the incident on 29 December 2017, the incident was reported to police the same day. The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Incorrect understanding of referral routes to the Approved Mental Health Practitioner Service
Wider context from the report “(3) The social work team leader dealing with this case was under the impression that referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made by a GP.
” Open source report
30 Apr 2015 William THOMPSON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of a smoke detection system in the bedroom View source Failure of social workers to consider bedroom smoke detection for particularly high-risk service users 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.
×
AI-generated summary
William THOMPSON · 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
William Thompson died in a fire at his supported-housing home after discarded cigarette ignited his bedding, and he was killed by smoke inhalation. Although smoke and heat detectors were installed in the hall and kitchen, there was no smoke detection system in his bedroom. The report raised concern that his social workers had not considered bedroom smoke detection despite his significantly raised fire risk from smoking, drinking and immobility.
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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Lack of a smoke detection system in the bedroom
Wider context from the report “The evidence I heard at inquest was that, whilst smoke and heat detectors were installed in Mr Thompson’s hall and kitchen, there was no smoke detection system in his bedroom .
He was known to be at significantly raised fire risk because of his smoking, drinking and immobility (he used a Zimmer frame). London Fire Brigade had been called to his home more than once in the past. However, his social workers never addressed their minds to the question of whether there was a smoke detector in his bedroom and, if not, whether that might be useful.
This seems to be an area that would benefit from exploration for particularly high risk service users.
” 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 Hackney; that does not assign responsibility.
PFD Monitor interpretation Failure of social workers to consider bedroom smoke detection for particularly high-risk service users
Wider context from the report “The evidence I heard at inquest was that, whilst smoke and heat detectors were installed in Mr Thompson’s hall and kitchen, there was no smoke detection system in his bedroom.
He was known to be at significantly raised fire risk because of his smoking, drinking and immobility (he used a Zimmer frame). London Fire Brigade had been called to his home more than once in the past. However, his social workers never addressed their minds to the question of whether there was a smoke detector in his bedroom and, if not, whether that might be useful .
This seems to be an area that would benefit from exploration for particularly high risk service users.
” 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