3 Jun 2025 Pellumb Olaj · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to account for relevant suicide risk history in housing decisions View source Lack of a mapped process for accounting for suicide risk history for new and existing tenants View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pellumb Olaj · 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
Pellumb Olaj, who had paranoid schizophrenia and a history of suicide attempts including attempts to jump from a high window, jumped from the sixth-floor balcony outside his flat on 30 October 2024 and was killed instantly. The principal concern was that Islington Council failed to take this history into account when housing him in a sixth-floor property in 2020, and it was unclear whether the council had mapped how to address this for new and existing tenants.
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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to account for relevant suicide risk history in housing decisions
Wider context from the report “Mr Olaj had paranoid schizophrenia and had attempted to kill himself in the past, including by trying to jump from a high window on more than one occasion, but Islington Council failed to take that into account in 2020 when housing him in a sixth floor property.
I heard at inquest that, in preparing for inquest (not immediately following Mr Olaj’s death), Islington has now recognised the need to take such matters into account, but I am not clear that it has mapped a way to do this for new and existing tenants.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Lack of a mapped process for accounting for suicide risk history for new and existing tenants
Wider context from the report “Mr Olaj had paranoid schizophrenia and had attempted to kill himself in the past, including by trying to jump from a high window on more than one occasion, but Islington Council failed to take that into account in 2020 when housing him in a sixth floor property.
I heard at inquest that, in preparing for inquest (not immediately following Mr Olaj’s death), Islington has now recognised the need to take such matters into account, but I am not clear that it has mapped a way to do this for new and existing tenants.
” 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 Use an amended homelessness assessment form that explicitly records household physical and mental health needs before accommodation offers.
Verbatim wording from the response “ii. Amended internal form.” Source location Response from Islington 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 Require specialist psychiatric evidence during homelessness applications when an applicant has a mental health condition or prior suicide attempt.
Verbatim wording from the response “i. New procedure for specialist psychiatric advice.” Source location Response from Islington 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 Investigate development of shared access between Housing Needs and Housing Management database modules.
Verbatim wording from the response “Changes to IT systems.” Source location Response from Islington 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 Operate a unified Housing Needs service covering homelessness applications through new-tenancy sign-up, with shared applicant information and database access.
Verbatim wording from the response “A re-organisation of the Housing Needs Service.” Source location Response from Islington 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 Conduct tenancy audits for all tenants and leaseholders within three years to identify vulnerabilities and enable support or referrals.
Verbatim wording from the response “iii. A strategy within the new structure for the named officer to complete effective tenancy audits, with all tenants and leaseholders (approximately 36,000 residents) being visited within three years. This will allow for vulnerable tenants to be identified, enabling appropriate support and referrals to be made. Prioritisation of audits is based on a number of data points” Source location Response from Islington 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 No concerns about the sixth-floor location were raised, and accommodation suitability could have been reviewed at any time thereafter.
Verbatim wording from the response “We have attached to this letter an appendix of documents. At pages 1 and 2 of the appendix appears a chronology of events which summarises pertinent details from prior to the offer of accommodation being made, until beyond Mr Olaj’s death. At no point either around the time of the offer of accommodation being made, nor subsequently, were any concerns raised to Islington by anyone, including Mr Olaj’s treating primary care physician, psychiatrist and specialist occupational therapist, about the location of his home on the 6th floor. Importantly, a review of its suitability could have been requested at any time in the years thereafter. As said by ████████ at the hearing, when she reviewed Mr Olaj in June 2022, he indicated that he was happy with his flat, and seeing his children.” Source location Response from Islington 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 Limited availability of ground- and first-floor council accommodation restricts the ability to provide lower-floor homes to every applicant requiring them.
Verbatim wording from the response “It does also seem prudent to highlight that the availability of Council accommodation is extremely limited, especially accommodation on the ground and first floor. Some applicants and tenants with physical disabilities may not be able to physically access accommodation that is above the ground floor and their needs must also be considered when suitable accommodation does become available.” Source location Response from Islington Council
Open published response
28 Mar 2025 Derrick Frederick Tully · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to record significant post-fall injuries in care notes View source Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting View source Failure to provide emergency access to the flat for carers and emergency services View source Failure to account for cognitive, mental health and home-safety barriers when assessing engagement View source Failure to award medical points despite evidence of unsuitable accommodation and health needs View source Failure to escalate significant post-fall injuries for medical review View source Inaccessible temporary accommodation for wheeled-walker use View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derrick Frederick Tully · 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
Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.
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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant post-fall injuries in care notes
Wider context from the report “On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting
Wider context from the report “On discharge from hospital on 3 February 2024 following a fall, Derrick was provided with a good package of care. On 23 February this changed to a reablement package of care. Derrick was not suitable for reablement because of his declining cognition and progressive dementia . The occupational therapist raised concerns that he was not suitable for reablement for these reasons and because there were no rehabilitation goals. There was an over-reliance on Derrick’s self-reporting which was inaccurate given his memory problems , and a focus on him doing more for himself. He began losing weight because he was not eating, and he was not able to cope with self-care.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to provide emergency access to the flat for carers and emergency services
Wider context from the report “Derrick required carers twice a day. He was also given a pendant alarm for emergencies. However, no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat . This was raised repeatedly by his family, carers and other professionals.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to account for cognitive, mental health and home-safety barriers when assessing engagement
Wider context from the report “Following MDT meetings due to concerns over Derrick’s increasing deterioration and ability to cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. They discharged him from the service on 12 March because he did not want to engage with their home assessment of him . Derrick was suffering from cognitive impairment as a result of previous strokes and newly diagnosed dementia. He also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team .
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to award medical points despite evidence of unsuitable accommodation and health needs
Wider context from the report “Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property. Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points .
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate significant post-fall injuries for medical review
Wider context from the report “On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February . “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor .
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Inaccessible temporary accommodation for wheeled-walker use
Wider context from the report “Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property . Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points.
” 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 Review the Key Safe Policy, including factors for deciding whether to install a key safe.
Verbatim wording from the response “Islington Council recognise the important role key safes can play in managing risk to individuals, as well the importance of resident consent, risk management and promoting independence and strength. In response to the PFD Notice Islington Council will inform the workforce through the Principal Social Worker the importance of considering access to people’s property in the event of risk, as well as the importance of contingency planning. In addition, Islington Council will undertake a review of its Key safe Policy which will include the factors to be considered when deciding to install.” Source location Response from Islington 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 Revisit training on identifying cognitive abilities, capacity, risk, and risk management under the Mental Capacity Act.
Verbatim wording from the response “In response to the coroner’s findings, Islington does support its workforce through training, audit and the support of the principal social worker with the skills to identify issues relating to residents’ cognitive abilities, their capability to identify risk and the management of that risk in line with the Mental Capacity Act 2005 and its principles. Islington Council will revisit this training in the light of the coroner’s findings.” Source location Response from Islington 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 Inform the workforce about considering property access risks and contingency planning, including the role of key safes.
Verbatim wording from the response “Islington Council recognise the important role key safes can play in managing risk to individuals, as well the importance of resident consent, risk management and promoting independence and strength. In response to the PFD Notice Islington Council will inform the workforce through the Principal Social Worker the importance of considering access to people’s property in the event of risk, as well as the importance of contingency planning. In addition, Islington Council will undertake a review of its Key safe Policy which will include the factors to be considered when deciding to install.” Source location Response from Islington 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 Daryel Care reported the fall to Adult Social Care, while ambulance attendance and hospital treatment had already addressed the immediate response.
Verbatim wording from the response “It is ASC’s understanding that Daryel Care was not requested to provide evidence to the coroner's court of their recording and reporting of the fall on the 20 February 2024. As part of ASC’s response to the PFD Notice, we have engaged Daryel Care who have provided their records. These evidence that on the 20 February 2024 at 19:12 ‘Derek sustained an injury on his face. He said he had an accident when he went out. The injury was plastered. I prompted his medication from the medication box, and he asked me to leave’.” Source location Response from Islington 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 The decision to provide Reablement was considered appropriate, lawful and consistent with practice because the resident could communicate his wishes and was previously independent.
Verbatim wording from the response “The PFD Notice states that the Coroners Court has determined that Derrick was not suitable for reablement because of his declining cognition and progressive dementia.” Source location Response from Islington 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 The access assessment and telecare emergency contacts were considered sufficient contingencies instead of immediate keysafe installation.
Verbatim wording from the response “ASC acknowledge that there was no keysafe in place, when Reablement support commenced. Mr Tully was assessed as being able to provide access to the property. This assessment would have been made in the context of Islington Council’s ASC practice model for promoting strengths-based practice and that Mr Tully had the mental capacity to make a decision about how he supported access to his property.” Source location Response from Islington 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 Opening the medical evidence would not have resulted in earlier housing because the resident died within 15 days amid severe social-housing shortages.
Verbatim wording from the response “If the letter received on 5th March 2024 had been opened/read on time and a medical assessment had been conducted, it would surely not have led to Mr Tully having been housed any sooner as he passed away within 15 days of receipt of the OT report. Regrettably, this is due to the severe shortage of social housing available in Islington.” Source location Response from Islington Council
Open published response
7 Aug 2024 Malika HIBU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to make an identified unsafe barrier safer or secure its remediation View source Failure to risk assess the canal barrier View source Failure to consider barrier safety during housing development planning View source Failure to act on resident complaints about the barrier View source Lack of knowledge of the ownership boundary View source Inadequate canal-side railing protection for children and adults View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Malika HIBU · 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
Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.
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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to make an identified unsafe barrier safer or secure its remediation
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer .
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess the canal barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal ;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to consider barrier safety during housing development planning
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development .
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to act on resident complaints about the barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier ;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the ownership boundary
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished ;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Inadequate canal-side railing protection for children and adults
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it .
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Share urban design lessons from the incident with all Development Management Officers.
Verbatim wording from the response “Finally, the urban design lessons learned from this incident have been shared with all Development Management Officers at Islington Council. We have also checked that a planning application for another canal side residential development includes fencing and have confirmation that this is the case.” Source location Response from Islington 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 Check that another canal-side residential development application includes fencing.
Verbatim wording from the response “Finally, the urban design lessons learned from this incident have been shared with all Development Management Officers at Islington Council. We have also checked that a planning application for another canal side residential development includes fencing and have confirmation that this is the case.” Source location Response from Islington 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 Work with Peabody to progress a planning application for safety fencing around the canal-side area of the Crest Buildings Estate.
Verbatim wording from the response “In terms of the Crest Buildings housing development, the Council is working proactively and positively with Peabody to bring forward a planning application for safety fencing around the canal side area of the Estate. The Council has held two senior level meetings with Peabody to discuss their planning application and to encourage them to submit the application in the most expedient manner possible. Once the application is submitted, we will deal with it promptly. We have also met with the residents of the Estate to explain the planning process and to encourage them to engage in that process.” Source location Response from Islington Council
Open published response
19 Jan 2023 Lance Scott Walker · Prevention of Future Deaths report West London
View report summary
Concerns raised 9 Insufficient scrutiny and approval of new accommodation providers View source Lack of regulatory oversight of supported accommodation for 18-21 year olds View source Lack of a standard referral form for supported housing service users aged 16-25 View source Insufficient contractual oversight of accommodation providers View source Insufficient provider knowledge of complex resident needs View source Inadequate checking and auditing of placement forms and referral information View source Inadequate staffing in supported accommodation View source Failure to perform adequate due diligence when matching individuals in accommodation View source Inadequate training among supported accommodation providers View source See 6 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
Lance Scott Walker · 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
Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.
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 Islington; that does not assign responsibility.
PFD Monitor interpretation Insufficient scrutiny and approval of new accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of supported accommodation for 18-21 year olds
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector , resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard referral form for supported housing service users aged 16-25
Wider context from the report “2 Response requested from London Borough of Ealing, London Borough of Islington and the West London Alliance
There is currently no standard referral form for service users aged 16-25 to be referred into supported housing. This means that best practise is not universally followed and it is more difficult for stakeholders to have to deal with a number of different forms. Vital information can potentially be missed and issues not highlighted when a variety of forms are used for the same referral procedure. Consideration should be given to adopting a standard form across the West London Alliance, or even a national standard using “best practise” as the benchmark, for clarity and ease of reference.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Insufficient contractual oversight of accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Insufficient provider knowledge of complex resident needs
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Inadequate checking and auditing of placement forms and referral information
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals , with consideration on the introduction of mandatory fields for specific information to be included . The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing in supported accommodation
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Failure to perform adequate due diligence when matching individuals in accommodation
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Islington; that does not assign responsibility.
PFD Monitor interpretation Inadequate training among supported accommodation providers
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training , staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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