30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
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Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids View source
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
Review risk assessments for providing life buoys at Council-owned inland water and publicly accessible sites.
View source
Action
Require newly procured buoyancy aids to comply with the relevant British Standard and include white stripes.
View source
Action
Consider lighting life buoys at Council-owned inland water and publicly accessible sites, completing the consideration within three months.
View source
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AI-generated summary
Liam Stephen Allan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.
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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 Havering; that does not assign responsibility.
PFD Monitor interpretation Delays in police alerting of the LFB and subsequent emergency response
Wider context from the report “The process for alerting the LFB by the Metropolitan Police Service (MPS) uses a telephone to transmit information from the MPS to the LFB , rather than using a CAD-mediated system to transfer information electronically from the Police to the LFB which is faster than transmitting information by telephone . This delay means that there is a risk that future deaths could occur due to a delay in the LFB being alerted by the Police and a corresponding delay to the LFB's subsequent response to an emergency incident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Havering; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of riverside buoyancy aids
Wider context from the report “The lighting of buoyancy aids on the riverside is not adequate , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
Buoyancy aids are more visible when painted with white stripes and/or reflective white stripes. However, not all buoyancy aids are so painted , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
” Open source report
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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 risk assessments for providing life buoys at Council-owned inland water and publicly accessible sites.
Verbatim wording from the response “As far as my enquiries have determined, the Council does not own any Thames Riverside buoyancy aids. The provision, maintenance and any lighting of buoyancy aids will often fall to riparian land owners. The Council does own inland bodies of water and publically accessible places next to these. Consideration and review of risk assessments as to the provision of life buoys at these sites was recently given. Further consideration as to the lighting of these will now be given and this will be completed within three months of this letter. The report findings will be reviewed as part of risk assessment processes going forward. The report findings have also been shared with known riparian owners in case they have publically accessible lifesaving equipment.” Source location Response from London Borough of Havering
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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 newly procured buoyancy aids to comply with the relevant British Standard and include white stripes.
Verbatim wording from the response “Whenever the Council procures new buoyancy aids we will ensure the purchase is as per the relevant British Standard foremost and the application of a white stripe(s) will be required.” Source location Response from London Borough of Havering
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 Consider lighting life buoys at Council-owned inland water and publicly accessible sites, completing the consideration within three months.
Verbatim wording from the response “As far as my enquiries have determined, the Council does not own any Thames Riverside buoyancy aids. The provision, maintenance and any lighting of buoyancy aids will often fall to riparian land owners. The Council does own inland bodies of water and publically accessible places next to these. Consideration and review of risk assessments as to the provision of life buoys at these sites was recently given. Further consideration as to the lighting of these will now be given and this will be completed within three months of this letter. The report findings will be reviewed as part of risk assessment processes going forward. The report findings have also been shared with known riparian owners in case they have publically accessible lifesaving equipment.” Source location Response from London Borough of Havering
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 Communication between emergency services is a matter for the emergency services, so no Council action is proposed.
Verbatim wording from the response “We consider this to be a matter for the emergency services to address. For this reason, no action by the Council is proposed.” Source location Response from London Borough of Havering
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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 Provision, maintenance and lighting of Thames riverside buoyancy aids will often be the responsibility of riparian landowners.
Verbatim wording from the response “As far as my enquiries have determined, the Council does not own any Thames Riverside buoyancy aids. The provision, maintenance and any lighting of buoyancy aids will often fall to riparian land owners. The Council does own inland bodies of water and publically accessible places next to these. Consideration and review of risk assessments as to the provision of life buoys at these sites was recently given. Further consideration as to the lighting of these will now be given and this will be completed within three months of this letter. The report findings will be reviewed as part of risk assessment processes going forward. The report findings have also been shared with known riparian owners in case they have publically accessible lifesaving equipment.” Source location Response from London Borough of Havering
Open published response
4 Sep 2020 Ellie Jessalyn Isaacs · Prevention of Future Deaths report East London
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Concerns raised 4 Risk of future deaths from the combined crossing hazards View source Obstruction of drivers' view of pedestrians waiting at the crossing View source Failure of vehicles to comply with automated traffic signals View source Hazardous crossing approach following a bend with a higher preceding speed limit View source See 1 more concern
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AI-generated summary
Ellie Jessalyn Isaacs · 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 19 June 2019, 22-year-old Ellie Isaacs was struck by a motor vehicle while crossing the A12 at a Pelican crossing in Romford before the pedestrian light turned green; she sustained fatal injuries and died in hospital on 21 June 2019. The concerns included obstructed driver views, the crossing’s location and changing speed limits, and high levels of vehicles failing to stop during the amber traffic-light phase, which together raised a risk of future deaths.
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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 Havering; that does not assign responsibility.
PFD Monitor interpretation Risk of future deaths from the combined crossing hazards
Wider context from the report “4. The combination of the above factors, raises a risk of future deaths .
” 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 Havering; that does not assign responsibility.
PFD Monitor interpretation Obstruction of drivers' view of pedestrians waiting at the crossing
Wider context from the report “1. The Inquest heard that there are a number of items of street furniture that obstruct the view that drivers should have of pedestrians waiting at the Pelicon crossing (signage, bus stand, safety camera and overhanging foliage/tree branches).
” 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 Havering; that does not assign responsibility.
PFD Monitor interpretation Failure of vehicles to comply with automated traffic signals
Wider context from the report “3. A recent site visit noted a very high level of non-compliance with the automated traffic signals . Vehicles were noted not to be stopping at the amber traffic light phase .
” 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 Havering; that does not assign responsibility.
PFD Monitor interpretation Hazardous crossing approach following a bend with a higher preceding speed limit
Wider context from the report “2. The Pelicon crossing is sited shortly following a bend in the road and the immediate speed limit approaching the crossing is 30 miles per hour. Very shortly before the Pelicon crossing, the speed limit is 50mph .
” Open source report
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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 No road bend causing driver sightline problems was apparent near the crossing during inspection.
Verbatim wording from the response “While on site there was no visible bend apparent in the carriageway along this length of the road that would cause any sight line issues for drivers what so ever.” Source location 2020-0169-Response-from-Havering-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 The Metropolitan Police is responsible for investigating and enforcing traffic-light and speed offences at the crossing.
Verbatim wording from the response “During the site visit on 17th September the non-compliance witnessed above was not seen. This may well be down to the fact that someone standing near the crossing point dressed in black wearing a high-viz jacket may have given the impression of a police presence in which case any comment here is possibly flawed. In London it is the Metropolitan Polices role to enforce traffic light control contraventions/speed offences etc. so it would fall to them to carry out any further necessary investigation at this particular site.” Source location 2020-0169-Response-from-Havering-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 Highway safety actions at the location fall outside Havering Council’s authority because Transport for London is the highway authority.
Verbatim wording from the response “While Colchester Road is part of the adopted highway network, Havering Council are not the Highway Authority for this road, this responsibility falls to Transport for London (TfL). The plan shown below shows the boundary of TfL’s responsibility around Gallows Corner roundabout and also the section of Colchester Road where the crossing point is situated.” Source location 2020-0169-Response-from-Havering-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 Transport for London must investigate and determine any action concerning the highway network at the location.
Verbatim wording from the response “A site inspection was undertaken on Thursday 17th September to look at the incident site so that Havering could give responses to the points raised in the coroner’s report. While these comments are made by a Senior Engineer at Havering it must be stressed that TfL would need to carry out their own investigation as they would be ultimately responsible for any action (or inaction) carried out to the highway network at this location.” Source location 2020-0169-Response-from-Havering-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 The reported high non-compliance with traffic signals was not observed during the Council’s site visit, although the observation may have been unreliable.
Verbatim wording from the response “3. A recent site visit noted a very high level of non-compliance with the automated traffic signals. Vehicles were noted not to be stopping at the amber traffic light phase.” Source location 2020-0169-Response-from-Havering-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 The inspected camera, vegetation, bus stand and signage did not obstruct drivers’ sightlines to the controlled crossing.
Verbatim wording from the response “The footway at this location is split into a cycle way at the rear of the footway with the pedestrian side adjacent to the carriageway. The safety camera is located at the rear of the footway approximately 25 metres before the crossing, within the cycle way section, and would not cause any sight line issues for car drivers approaching the controlled crossing point.” Source location 2020-0169-Response-from-Havering-Council-_Redacted.pdf
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2 Mar 2014 Lauren Marie Brown and Stephen Michael Tilbury · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 1 Failure to control vehicle speeds on approach to the bend View source
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
Lauren Marie Brown and Stephen Michael Tilbury · 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
Stephen Michael Tilbury died at the scene after losing control of his van on Crow Lane while over the legal alcohol limit and travelling above the speed limit. Lauren Marie Brown was struck by the van on the pavement and died in hospital in the early hours of the following day. The principal concerns were speeding at the bend and whether physical measures should be used to reduce vehicle speeds and manage the risks associated with the kerb.
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 Havering; that does not assign responsibility.
PFD Monitor interpretation Failure to control vehicle speeds on approach to the bend
Wider context from the report “1. Evidence was heard from eye witnesses to the collision. One witness who knows the area very well stated, “I am well used to tyres screeching in Crow Lane, people are always driving too quickly in Crow Lane.” The Senior Investigating Officer also gave evidence to confirm that local residents are concerned about speeding in that area .
2. The Collision Investigator gave evidence to confirm that in order to reduce the risk of death in the future, steps should be taken to put something physical in place, on the road, to help ensure that vehicles are travelling at the speed limit on approach to the bend . Such physical measures might be speed bumps. Another possibility that he considered was for another brief curb to be put on the south footway (mirroring the opposite curb), to deflect vehicles away from the pavement and back into the road.
3. The Senior Investigating Officer also confirmed that measures should be taken to slow vehicles down . She confirmed that physical measures, such as speed bumps, would be of greater value than illuminated or other signs.
” 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