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
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
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 Lambeth; 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 Lambeth; 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
21 Dec 2020 Brian JAMES EASEY · Prevention of Future Deaths report West Sussex
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Concerns raised 2 Potential asbestos-fibre contamination of council records View source Risk of asbestos exposure from contaminated council records 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. 1
Action
Commission and complete asbestos inspections, laboratory testing and air sampling of representative Registrar’s records at all three storage locations.
View source
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AI-generated summary
Brian JAMES EASEY · 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
Brian James Easey was diagnosed with biphasic mesothelioma in September 2020 and died from the condition on 13 December 2020. The report raises concerns that asbestos fibres may remain on council records and could expose people who come into contact with them, with an associated risk of fatal mesothelioma.
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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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Potential asbestos-fibre contamination of council records
Wider context from the report “(1) In view of Mr Easey’s description of the dust present on the council records in both locations there appears to me a real risk that these records were, and remain, contaminated with asbestos fibres ;
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Risk of asbestos exposure from contaminated council records
Wider context from the report “(2) Should there currently be asbestos fibres present on the records this presents a risk of asbestos exposure to all those whose come into contact with the records with an associated risk of developing fatal mesothelioma.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete asbestos inspections, laboratory testing and air sampling of representative Registrar’s records at all three storage locations.
Verbatim wording from the response “16. The Council had commissioned detailed reports from external asbestos specialists in relation to the records held at each of these three locations, some of which will have been stored at 340 and/or 357-363 Brixton Road at some point in the past. The results of those tests are set out below under the heading “outcome of testing”.” Source location 2020-0293-Response-from-Lambeth-Legal-Services-Redacted
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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 Inspections found no asbestos contamination or associated risk in Registrar’s records, so further asbestos-related action is not proposed.
Verbatim wording from the response “2. In summary, we can inform the Coroner that reports produced by Ayerst, an external asbestos specialist, following extensive inspections have confirmed that there is no contamination of the Council’s Registrar files that were once held at 340 Brixton Road (and at other offices used by the Council’s Registrar’s Office in the past). Further details are set out below. In view of these findings the Council does not intend to take any further action.” Source location 2020-0293-Response-from-Lambeth-Legal-Services-Redacted
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30 Jun 2018 Yunis Malik Hadi · Prevention of Future Deaths report Inner South London
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Concerns raised 3 Lack of formal first-aid and choking-response training among adult volunteers and teachers View source Lack of a defibrillator View source Lack of oversight of current first-aid emergency training, supervision and child safeguarding arrangements 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. 5
Action
Advise the Centre to specify safeguarding policies and procedures in its lettings policy.
View source
Action
Follow up the identified actions through safeguarding training and a Food, Health and Safety Manager visit.
View source
Action
Provide the Centre with a model safeguarding policy and offer local-authority support.
View source
Action
Advise the Centre about accessible first-aid training and provide training details.
View source
Action
Undertake a safeguarding audit of the Centre.
View source See 2 more actions
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AI-generated summary
Yunis Malik Hadi · 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 28 January 2018, Yunis Malik Hadi choked and collapsed while eating a snack at a Sunday school, and could not be resuscitated despite CPR efforts. The concerns included inadequate first-aid training for volunteers, lack of emergency medical equipment such as a defibrillator, and insufficient oversight of training, supervision and child safeguarding.
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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Lack of formal first-aid and choking-response training among adult volunteers and teachers
Wider context from the report “(1) A lack of formal training among the adult volunteers/teachers in first aid including response to choking incidents.
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Lack of a defibrillator
Wider context from the report “(2) A lack of emergency medical equipment i.e. a defibrillator.
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of current first-aid emergency training, supervision and child safeguarding arrangements
Wider context from the report “(3) A lack of oversight to ensure first aid emergency training, supervision and child safeguarding is kept up to date and in place at all relevant time.
” 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 Advise the Centre to specify safeguarding policies and procedures in its lettings policy.
Verbatim wording from the response “The Centre allows others to use the setting at the weekend and the Centre has therefore been advised by the Local Authority’s safeguarding manager that it needs to have safeguarding children policies and procedures explicitly stated in their lettings policy.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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 Follow up the identified actions through safeguarding training and a Food, Health and Safety Manager visit.
Verbatim wording from the response “The Charity Commission will be advised of this letter to enable their action and follow-up. Additionally Lambeth Council (schools safeguarding team) will follow-up on the actions indicated above through the safeguarding training taking place in mid-September and also via a visit by the Council’s Food, Health and Safety Manager. As indicated, we do not have any specific enforcement powers in relation to these matters. Any further findings from the Wandsworth Child Death Overview Panel, once completed, will be undertaken by Lambeth Council and its statutory partners once that review has concluded and its recommendations are known.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the Centre with a model safeguarding policy and offer local-authority support.
Verbatim wording from the response “It is clearly crucial that the provision has in place an adequate and appropriate safeguarding policy. The Charity Commission states what such a policy should include. Further support has been offered by the Local Authority and the model policy for schools has been shared with the Centre. The Charity Commission are also available to support and have resources on their website.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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 Advise the Centre about accessible first-aid training and provide training details.
Verbatim wording from the response “The local authority does not offer free first aid training, however, subsequent to the incident the Education Safeguarding Manager contacted the Centre to advise about training that can be accessed through agencies such as St John's Ambulance or the British Red Cross.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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 Undertake a safeguarding audit of the Centre.
Verbatim wording from the response “3. A safeguarding audit of the Centre was undertaken by the Lambeth School Safeguarding Manager (9th August 2018).” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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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 local authority has no specific enforcement powers in relation to the identified safeguarding, training and supervision matters.
Verbatim wording from the response “The Charity Commission will be advised of this letter to enable their action and follow-up. Additionally Lambeth Council (schools safeguarding team) will follow-up on the actions indicated above through the safeguarding training taking place in mid-September and also via a visit by the Council’s Food, Health and Safety Manager. As indicated, we do not have any specific enforcement powers in relation to these matters. Any further findings from the Wandsworth Child Death Overview Panel, once completed, will be undertaken by Lambeth Council and its statutory partners once that review has concluded and its recommendations are known.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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 There is no legal requirement for the Centre to have a defibrillator.
Verbatim wording from the response “There is no requirement in law for an establishment to have a defibrillator, however, following a conversation between Lambeth Council’s Senior Schools and Education Improvement Adviser (1st August 2018), the Chair of Trustees of the Centre has advised that a defibrillator and training would be purchased.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
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 local authority does not offer free first-aid training, limiting its ability to provide that training directly.
Verbatim wording from the response “The local authority does not offer free first aid training, however, subsequent to the incident the Education Safeguarding Manager contacted the Centre to advise about training that can be accessed through agencies such as St John's Ambulance or the British Red Cross.” Source location 2018-0209-Response-by-London-Borough-of-Lambeth
Open published response
20 Feb 2015 Maria Nekrasova · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Inadequate night-time lighting of the bridge carriageway View source Lack of prevention of pedestrian crossing of the bridge carriageway View source Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare View source Lack of protection for pedestrians in the middle of the bridge carriageway View source See 1 more concern
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maria Nekrasova · 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
Maria Nekrasova was struck by a licensed taxi while standing in the hatched area in the middle of Westminster Bridge carriageway at about 1.50 am on 4 May 2014, sustaining a severe traumatic head injury from which she died. Concerns included the absence of pedestrian barriers or protection in the carriageway, low and contrasting street lighting, and vehicle headlight glare affecting drivers’ ability to see pedestrians.
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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Inadequate night-time lighting of the bridge carriageway
Wider context from the report “(2) At night the level of street lighting is low , the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness ;
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Lack of prevention of pedestrian crossing of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation);
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare
Wider context from the report “(3) The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting them.
” 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 Lambeth; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for pedestrians in the middle of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation) ;
” 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