30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
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 Lewisham; 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 Lewisham; 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
29 Jan 2025 Naomi SULEYMAN · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to make accurate referrals to the District Nursing team View source Failure of communication between D2A therapists and District Nurses View source Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs View source Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge View source Lack of capacity in the in-house Enablement team View source Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process View source Delays in District Nursing assessment after referral View source Failure to provide an out-of-hours social worker welfare check on the day of discharge View source Failure to identify deficient discharge passports during Hospital Flow Centre screening 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.
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AI-generated summary
Naomi SULEYMAN · 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
Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate referrals to the District Nursing team
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge . This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between D2A therapists and District Nurses
Wider context from the report “(2) There was little communication between the therapists from the D2A team and the District Nurses .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs
Wider context from the report “(1) The ‘discharge passport’ completed by the UHL in-patient team was inaccurate , failing to record Ms Suleyman’s vulnerability to pressure ulcers, the need for therapies input from day 1, the equipment she required and that her home environment had not been optimised to meet her needs both in terms of equipment and layout . Whilst I heard that scrutiny of the discharge passport had improved at ward level, deficient discharge passports were still filtering through to the D2A 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge
Wider context from the report “(4) Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity in the in-house Enablement team
Wider context from the report “(4) Due to lack of capacity , Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process
Wider context from the report “The issues relating to LBL only emerged in evidence during the inquest. LGT in-patient and District Nursing services have taken some steps towards addressing their deficiencies. However, there has been a fragmented and incomplete response . There has been no overarching coordinated investigation involving all the key services relevant to what is intended to be an integrated multi-disciplinary discharge process .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Delays in District Nursing assessment after referral
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge. This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an out-of-hours social worker welfare check on the day of discharge
Wider context from the report “(3) On the day of discharge, Ms Suleyman should have received a welfare check from the LBL out of hours social worker which did not happen .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deficient discharge passports during Hospital Flow Centre screening
Wider context from the report “(2) The deficiencies in the discharge passport were not identified when it was screened by the LGT Hospital Flow Centre .
” Open source report
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Install up to 75 additional diffusion-tube and PM₂.₅ monitors by October 2021.
Verbatim wording from the response “in the process of adding several new monitors to monitor PM₂.₅, particularly in areas of high traffic. Due to technological advances, the measurement of PM₂.₅ no longer requires a large automatic monitoring station and more flexible monitors can now be placed around the Borough. These will feed into a London wide network of sensors providing greater data and coverage and will help to contribute to improved public awareness of air pollution levels across the capital. We are also in the process of adding yet more diffusion tubes, with up to another 75 monitors in total (both diffusion tubes and the new PM₂.₅ monitors) planned for installation by October this year.” Source location 2021-0113-Response-from-London-Borough-of-Lewisham-Redacted
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 Establish and operate the Honor Oak Park supersite and expand diffusion-tube monitoring to 106 sites.
Verbatim wording from the response “• An expansion of monitoring capacity: at the time of Ella’s tragic death there were diffusion tubes monitoring NO₂ levels at 47 sites and 4 automatic monitoring stations measuring, variously NO₂, PM₁₀ and SO₂ levels. The most significant addition shortly after Ella’s death was the creation of the Honor Oak Park ‘supersite’ automatic monitoring station which opened on 1 January 2019 and which monitors PM₁₀ and PM₂.₅. Further, by the end of 2020 the number of diffusion tube sites more than doubled to 106. Since the Inquest, capacity has grown even further and we are introducing important new technology as we are” Source location 2021-0113-Response-from-London-Borough-of-Lewisham-Redacted
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 Continue collaborative air-quality awareness work with the GLA, other local authorities and committed organisations.
Verbatim wording from the response “Finally, the London Borough of Lewisham will continue to work collaboratively and in partnership with the GLA, other local authorities and organisations who are committed to raising awareness of air quality issues. The important collaboration with the GLA includes ‘Breathe London’ which the Mayor of London has agreed to support until 2024. We have recently been in close discussion with counterparts at the GLA and are eager to support their important work in this field.” Source location 2021-0113-Response-from-London-Borough-of-Lewisham-Redacted
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 Implement a multimedia communications plan promoting air-quality monitoring tools through social media, advertising, websites and the residents’ newsletter.
Verbatim wording from the response “• Raising awareness: As the London Borough of Lewisham highlighted during the Inquest, the raising of awareness of air quality issues has improved significantly since Ella’s death. This is partly as a result of the transfer of the public health functions from the NHS to the Borough in April 2013, which led to a Joint Strategic Needs Assessment for Air Quality in 2018, which will be refreshed again in 2022 (and which has a target audience of those who commission, provide or use health, social or children’s services in Lewisham). It has also improved due to technology and social media, so that the London Borough of Lewisham is able to promote airTEXT, the Imperial College London Air webpage, the GLA air quality web page/alerts, and even its own air quality App. However, there is more work that can and will be done.” Source location 2021-0113-Response-from-London-Borough-of-Lewisham-Redacted
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 Add several flexible PM₂.₅ monitors, particularly in high-traffic areas, to feed the London-wide sensor network.
Verbatim wording from the response “• An expansion of monitoring capacity: at the time of Ella’s tragic death there were diffusion tubes monitoring NO₂ levels at 47 sites and 4 automatic monitoring stations measuring, variously NO₂, PM₁₀ and SO₂ levels. The most significant addition shortly after Ella’s death was the creation of the Honor Oak Park ‘supersite’ automatic monitoring station which opened on 1 January 2019 and which monitors PM₁₀ and PM₂.₅. Further, by the end of 2020 the number of diffusion tube sites more than doubled to 106. Since the Inquest, capacity has grown even further and we are introducing important new technology as we are” Source location 2021-0113-Response-from-London-Borough-of-Lewisham-Redacted
Open published response
29 May 2020 Master Omarian Brooks · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Dispute over hospital destination during ambulance transfer View source Failure to inform the GP of patient deterioration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Master Omarian Brooks · 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
Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Dispute over hospital destination during ambulance transfer
Wider context from the report “2. There was also a distressing dispute between the ambulance crew and parents as to which hospital Omarian should be taken , in the event he was not taken to the nearest hospital at the insistence of his parents (although in this instance the delay was not found to have contributed to the death).
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of patient deterioration
Wider context from the report “1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after , he would have been admitted to hospital with a real prospect of the infection being successfully treated.
” Open source report
27 Mar 2019 Ms Donna Williamson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to assign responsibility for repairing and securing doors in privately rented accommodation View source Failure to inform victims promptly when suspects are released on bail View source Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk View source Failure to contact available support services for disabled private tenants View source Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Donna Williamson · 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
Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for repairing and securing doors in privately rented accommodation
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not . Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to inform victims promptly when suspects are released on bail
Wider context from the report “2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk
Wider context from the report “4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge or awareness of their professional and legal duties of disclosure.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure to contact available support services for disabled private tenants
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted . Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals
Wider context from the report “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals . She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it.
” Open source report
21 Dec 2018 Paul Fairey · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Deterioration of speed-cushion surface View source Obstruction of street-lamp lighting by tree foliage View source Speed cushion failing to require vehicles to slow down View source Failure of painted SLOW road marking to remain clearly visible to motorists View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Fairey · 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
Paul Fairey was a pedestrian who was struck by a northbound car on Mayow Rd at about 00.40 on 23 September 2017 and later died from a severe head injury. Concerns included poor visibility caused by tree foliage, a faded road marking, and a speed cushion that could be straddled and was beginning to break up; the evidence also indicated that the car was travelling above the 20mph speed limit.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Deterioration of speed-cushion surface
Wider context from the report “(3) There is a speed cushion close to the pedestrian crossing point. The evidence was that a car can straddle this speed cushion without needing to slow down. Also the speed cushion is beginning to break up .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Obstruction of street-lamp lighting by tree foliage
Wider context from the report “(1) The street lamp nearest to the collision site (8m south of De Frene Rd, on the east side of Mayow Rd) was shrouded by tree foliage causing a large shadow across Mayow Rd . This shadow encompassed the site of the collision and the nearby pedestrian crossing point .
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Speed cushion failing to require vehicles to slow down
Wider context from the report “(3) There is a speed cushion close to the pedestrian crossing point. The evidence was that a car can straddle this speed cushion without needing to slow down . Also the speed cushion is beginning to break up.
” 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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Failure of painted SLOW road marking to remain clearly visible to motorists
Wider context from the report “(2) There is a painted “SLOW” on the north bound lane near to the collision site. The evidence was that this sign has faded and may not be clearly visible to a motorist .
” 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 Arrange cutting back privately owned tree foliage to the highway boundary near the collision site.
Verbatim wording from the response “Response - The trees under consideration are privately owned. Letters were sent to the adjacent property owners in May 2018 requiring that they cut back the tree foliage to the highway boundary. As no action has been taken the Council is arranging for the foliage to be cut back. The work is expected to be completed by the end of February 2019.” Source location Response from Lewisham
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 Remark the northbound and southbound “SLOW” road markings approaching the pedestrian crossing.
Verbatim wording from the response “Response - The northbound "SLOW" marking approaching the crossing point was remarked in December 2017. The southbound slow marking approaching the crossing point was also remarked.” Source location Response from Lewisham
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 Reconstruct speed cushions near the two pedestrian refuge crossing points adjacent to Mayow Park.
Verbatim wording from the response “Response - The speed cushions in Mayow Road have been in place for a number of years and may be less effective due to long term wear. Financial constraints generally mean that widespread renewal of worn traffic calming features is not feasible. However it is proposed to reconstruct the speed cushions in close proximity of the two pedestrian refuge crossing points adjacent to Mayow Park to ensure that they are as effective as possible. This work is programmed to be completed by the end of April 2019.” Source location Response from Lewisham
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 Financial constraints mean widespread renewal of worn traffic-calming features is not feasible; only cushions near the crossings will be reconstructed.
Verbatim wording from the response “Response - The speed cushions in Mayow Road have been in place for a number of years and may be less effective due to long term wear. Financial constraints generally mean that widespread renewal of worn traffic calming features is not feasible. However it is proposed to reconstruct the speed cushions in close proximity of the two pedestrian refuge crossing points adjacent to Mayow Park to ensure that they are as effective as possible. This work is programmed to be completed by the end of April 2019.” Source location Response from Lewisham
Open published response
22 Sep 2016 DAPHNE MCCORKLE · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 1 Lack of nighttime care provision for patients requiring regular turning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
DAPHNE MCCORKLE · 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
Daphne McCorkle was discharged from hospital with a Grade 2 pressure sore, which deteriorated while she was receiving community care. She died in hospital on 20 November 2014 from sepsis caused by the infected pressure sore. Concerns included the frequency and quality of District Nurse visits and assessments, inadequate care-plan reviews and documentation, delayed referral to a Tissue Viability Nurse, lack of advice about night-time turning, and a gap in night-time care provision.
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 Lewisham; that does not assign responsibility.
PFD Monitor interpretation Lack of nighttime care provision for patients requiring regular turning
Wider context from the report “(1) On the expert evidence, there will be cases where a patient should be turned every 2/3 hours, even at night , to ensure that the risk of pressure sores being caused or worsened is properly managed.
(2) In some cases where this level of turning is required, family members will not be able to perform that task .
(3) However I was informed during the inquest that Lewisham District Nurses (for whom I understand the NHS Lewisham Clinical Commissioning Group is responsible) will not visit patients at home at night.
(4) I was also informed that agency carers (whose care I understand is commissioned by the London Borough of Lewisham, Adult Social Care Department) will not visit at night either.
(5) This leaves a gap in provision for some patients and is a concern.
” 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