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
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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 Southwark; 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 Southwark; 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
17 Aug 2023 Shirley Frances Ashelford · Prevention of Future Deaths report Inner South London
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Concerns raised 6 Failure to provide inspectors with information about recent hoist problems View source Lack of service-provider awareness of positional asphyxia risks during hoisting View source Lack of user and carer awareness of positional asphyxia risks during hoisting View source Failure to train carers in emergency lowering using the hoist red cord View source Possible design fault in hoist lowering function View source Failure of OT and AMT to share information about hoist condition 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
Shirley Frances Ashelford · 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
Shirley Frances Ashelford died after the lowering mechanism of a ceiling hoist failed while she was transferring from her bed to a mobility scooter, leaving her suspended in a chest harness. The harness tightened and, in combination with respiratory weakness caused by multiple sclerosis, led to fatal asphyxia. Concerns included inadequate awareness and training about positional asphyxia and emergency lowering, failures to share information about reported hoist problems, and a possible design fault in the hoist's lowering function.
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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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Failure to provide inspectors with information about recent hoist problems
Wider context from the report “5) I am concerned that the Bureau Veritas inspection report of 30/6/21 made no reference to the report of Higher Elevation and Shirley’s complaint on 9/4/21 indicating that the inspector was unaware of recent problems . Had they been aware they might have been able to detect the problem which caused the failure of the hoist to lower on the 20/7/21.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Lack of service-provider awareness of positional asphyxia risks during hoisting
Wider context from the report “1) The risk of fatal positional asphyxia associated with the use of harnesses/slings when hoisting was not appreciated by the OT services and AMT concerned with the provision, use and maintenance of the hoist. This indicates that training may be required to raise awareness of the risk of positional asphyxia in order to reduce the risk of future deaths. I consider it important to highlight to service providers the dangers associated with unassisted use of ceiling hoists and sling harnesses.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Lack of user and carer awareness of positional asphyxia risks during hoisting
Wider context from the report “2) Users and carers did not appear to have been made aware of the asphyxia risk associated with hoisting . It was not clear whether Shirley was trained in the use of the red cord safety feature on the hoist as there was no documentation to confirm this. Her husband and carer had never received training in the use of the red cord for emergency lowering. He was also unaware of the risks of positional asphyxia when Shirley was operating the hoist on her own . My concern is that there may be a general a lack of training of users and carers in the operation of this type of hoist and the risk of positional asphyxia.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Failure to train carers in emergency lowering using the hoist red cord
Wider context from the report “2) Users and carers did not appear to have been made aware of the asphyxia risk associated with hoisting. It was not clear whether Shirley was trained in the use of the red cord safety feature on the hoist as there was no documentation to confirm this. Her husband and carer had never received training in the use of the red cord for emergency lowering . He was also unaware of the risks of positional asphyxia when Shirley was operating the hoist on her own. My concern is that there may be a general a lack of training of users and carers in the operation of this type of hoist and the risk of positional asphyxia.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Possible design fault in hoist lowering function
Wider context from the report “4) There was some evidence that another hoist of the same model in the bathroom had a problem with the lowering function and the possibility of a fault in the design of the lowering function . I raise this concern to alert the MHRA and Prism Medical UK Ltd in order to conduct appropriate safety investigations. The hoists are available in situ for a limited period or otherwise will be kept in storage by the Local Authority for inspection purposes.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Failure of OT and AMT to share information about hoist condition
Wider context from the report “3) I am concerned that two departments in the local authority, the OT department and AMT, did not share information concerning the condition of the hoist , namely, Shirley’s reports to OT were not shared with AMT and visit reports from contractors to AMT were not shared with the OT . Likewise, the Bureau Veritas inspection on 30/6/21 appears to have occurred in an information vacuum regarding recent problems with the hoist. Whilst the Veritas inspection report was shared with the AMT it was not shared with the OT department.
” 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 Maintain quarterly interdepartmental meetings with self-hoisting as a standing agenda item and Asset Management Engineering Services attendance to communicate equipment concerns and remedial action.
Verbatim wording from the response “24. Currently, there is a regular quarterly meeting between AMT/HAT and the OT team. Following the inquest, self – hoisting cases and the issues arising therefrom, has become a rolling item on the agenda. AMT/ES will also now be attending these meetings. As part of this, AMT will make OT aware of any engineering concerns regarding equipment in situ, being used by self – hoisters and action that is being taken to resolve such concerns.” Source location Response from Southwark Council
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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 Establish a shared fault-repair reporting system recording mobility-equipment callouts and making information available to relevant asset-management and Occupational Therapy teams and inspection providers.
Verbatim wording from the response “21. It was also established that OT or AMT/HAT did not have direct access to the fault repair records. Steps have now been put in place to remedy this such that both OT and /or AMT/HAT can access relevant fault repair records, as required – this is explained further below.” Source location Response from Southwark Council
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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 Develop and establish a self-hoisting policy and checklist covering risk warnings, equipment checks, emergency plans, fault reporting and competency confirmation.
Verbatim wording from the response “8. Whilst it was accepted during the inquest that LBS had taken steps to protect Ms Ashelford by offering a care package, a pendant alarm and a micro environment in a room downstairs when she started reporting concerns with her hoist, LBS has reflected upon matters that arose in the inquest. As part of this LBS has now developed a policy and checklist, titled “Self Hoisting Policy London Borough of Southwark”, which is to be followed in the event LBS is working with a service user who expresses the motivation and demonstrates both the mental and physical capacity to use a hoist independently. As set out above, there are no current service users who fit this categorisation. However, the policy is now in place in the event that such occurs in the future.” Source location Response from Southwark Council
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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 Implement the True Compliance information-technology solution to store and provide stakeholder access to property-linked service and inspection reports.
Verbatim wording from the response “vi. The AMT department has procured the services of “True compliance” to deliver an IT compliance solution. This will enable the council to store multiple data information sources against a property file and provide access to a range of users. The intention is that the service reports and inspection reports will be stored and that access can be provided to all stakeholders to include OT and the inspection provider. The system allows access to be via an app, which can be downloaded to handheld devices and used whilst on site. It is expected that it will take at least a year to put this in place. It should be noted that to prevent OT being provided with excessive information they will not access these reports regularly and will instead, be provided with information at the quarterly meetings.” Source location Response from Southwark Council
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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 Place the self-hoisting policy on the case-management system, share it with relevant staff and include it in new-starter induction.
Verbatim wording from the response “10. This new policy (which contains a checklist) will be placed on Adult Social Care’s internal case management system and the information will shared by the Occupational Therapy Team Manager and Principal Occupational Therapist with all relevant staff. It will also be included in the new starter induction to advise new starters within the service. LBS also proposes to have a training session on the new policy. This training will be provided to the approximately 23 OTs who are currently employed by LBS’ Social Care. It will also include OT apprentices and students, team managers and health colleagues (that is, OTs, sitting within Health e.g. the reablement team that will be invited).” Source location Response from Southwark Council
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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 Providing inspectors with additional service records or operational information would not be relevant or alter the outcome of statutory inspections conducted under specified requirements.
Verbatim wording from the response “28. AMT/ES team has met with the local authority’s current inspection provider, HSB Engineering Insurance Limited (HSB), to discuss the concerns raised by HM Coroner as to the sharing of background information/previous inspection reports. In response to the question about supplying them with service records and operational information, HSB has stated that the provision of additional information other than whether the asset was at the location or in use would not be of particular relevance for their independent inspection. The reason for this being that these are statutory inspections which are governed by the provisions of the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER), safe working practices laid out by industry standard and company method statements.” Source location Response from Southwark Council
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 available evidence indicated that the hoist was serviceable, operational and safe, with no evident fault during the final service and inspection visits.
Verbatim wording from the response “26. The recommendation (by the AMT/ES’ contractor) for the replacement of the bedroom-ceiling hoist was based on the fact that a number of callouts had been made in previous months; that recommendation was not based on any evidence to suggest the equipment was unsafe or potentially unsafe to use. Job sheets and service sheets from Higher Elevation produced as evidence at the inquest portrayed the condition of the equipment as serviceable, of good working order and that many key parts had been replaced. The last call recorded by Higher Elevation on 09/04/21 recorded the equipment as “working”.” Source location Response from Southwark Council
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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 Routine sharing of every email or document with Occupational Therapy is not required; departmental arrangements provide relevant information when equipment issues arise.
Verbatim wording from the response “17. In relation to sharing information between the Occupational Therapy team and the Asset Management Team: this was a deliberate decision. There were, and remain concerns, that the O.T. team will be overburdened by information if they are sent every email or piece of paperwork. The purpose behind having a division of departments is so they can focus their resources on matters where their expertise is. That said: if there are issues with a piece of equipment, of course the Occupational Therapist needs to know.” Source location Response from Southwark Council
Open published response
20 Feb 2017 Esther HartSilver · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Junction design permitting left-turning traffic from Lane 2 to cross straight-ahead traffic View source Lack of road-surface warning of turning-traffic conflict View source Failure of junction information to warn cyclists of vehicles turning across the bus lane View source Ambiguous road-surface indication of the bus-lane termination 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
Esther HartSilver · 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
Esther HartSilver died after being seriously injured when an HGV lorry turning left at the junction of Denmark Hill and Orpheus Street collided with her bicycle as she cycled to work. The report raises concerns about the junction’s design, including the risk created by traffic turning across the bus lane, inadequate warning of potential conflicts, and a history of reported collisions and near misses involving vulnerable road users.
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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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Junction design permitting left-turning traffic from Lane 2 to cross straight-ahead traffic
Wider context from the report “The junction predisposes itself to the very risk materialising that sadly caused Miss HartSilver’s death. Traffic wishing to turn left may, at the moment, turn left from Lane 2. This means that they cross a lane of traffic that may well be travelling straight ahead. Miss HartSilver was an experienced London cyclist and the HGV driver an experienced driver also. It is the junction that is unusual.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Lack of road-surface warning of turning-traffic conflict
Wider context from the report “It may not be unusual for a lorry turning into a side road to have to cross a bus lane. The junction can be distinguished from this, however. This is a more major junction than it appears. It is a major because it feeds all the traffic that would have wanted to turn right as well as left, from a very busy road into what is effectively a side road. Further, it has a pedestrian crossing just before it. This means that although there is an early sign warning traffic of the banned right turn and to turn left instead, there are mandatory zig-zag lines on the road leading up to the junction and therefore there is no signage on the road surface warning any user of the potential for conflict.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Failure of junction information to warn cyclists of vehicles turning across the bus lane
Wider context from the report “I am told if the bus lane were to end earlier there would still be a risk with larger vehicles needing to swing into lane 2, from lane 1, in turning the corner. It would not reduce the risk to zero. I understand all that. If I was cycling in that bus lane, even having seen the sign saying that there is a left turn for those wanting to turn right ahead, I would not be reminded of the risk of vehicles turning anything in the road layout. There is also a significant amount of traffic turning across a bus lane.
” 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 Southwark; that does not assign responsibility.
PFD Monitor interpretation Ambiguous road-surface indication of the bus-lane termination
Wider context from the report “The red coloured road surface that is present in the bus lane goes across this junction and will make vehicles think it is still a bus lane. Officially, the bus lane stops because the zig-zags take over as there is a pedestrian crossing present immediately before the turning on the left.
” 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 Install raised entry treatment at the Orpheus Street–Denmark Hill junction to encourage vehicles to slow when turning.
Verbatim wording from the response “4. The installation of entry treatment (whereby the entrance to the side road is raised to the level of the adjacent footway, to encourage vehicles turning into the side road to slow down on the approach) on Orpheus Street at the junction with Denmark Hill. The photograph below shows the entry treatment applied to another junction within the borough and it is intended to apply a similar treatment to the junction of Orpheus Street/Denmark Hill.” Source location 2017-0052-Response-by-Southwark-Council
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 Paint cycle symbols at the Denmark Hill–Orpheus Street junction to highlight cyclists in the nearside lane.
Verbatim wording from the response “1. Cycle symbol markings being painted on Denmark Hill, at the junction with Orpheus Street to highlight presence of cyclists using the nearside lane;” Source location 2017-0052-Response-by-Southwark-Council
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 Install durable cycle-symbol markings near the Denmark Hill–Orpheus Street junction to highlight cyclists in the nearside lane.
Verbatim wording from the response “The following long-term safety improvements were agreed to proceed and be implemented by Southwark as part of the Denmark Hill town centre upgrade project (during 2017-18), subject to design, feasibility and safety audit:” Source location 2017-0052-Response-by-Southwark-Council
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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 Remove the southbound bus-lane line between bus stop Q and the existing pelican-crossing zig-zag lines.
Verbatim wording from the response “2. The removal of bus lane line on the southbound lane between bus stop Q and the existing pelican crossing zig-zag lines; and” Source location 2017-0052-Response-by-Southwark-Council
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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 Install left-turn and through-lane arrows between bus stop Q and the existing pelican-crossing zig-zag lines.
Verbatim wording from the response “3. The installation of left turn lane arrows on the nearside lane, and through arrows on the offside lane between bus stop Q and the existing pelican crossing zig-zag lines, subject to available space.” Source location 2017-0052-Response-by-Southwark-Council
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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 Install durable left-turn and through-lane arrows between the relocated bus stop Q and the pelican-crossing zig-zag lines.
Verbatim wording from the response “The following long-term safety improvements were agreed to proceed and be implemented by Southwark as part of the Denmark Hill town centre upgrade project (during 2017-18), subject to design, feasibility and safety audit:” Source location 2017-0052-Response-by-Southwark-Council
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 Install an advisory sign specifying left-turn-only movement except buses in the nearside lane and through movement only in the offside lane.
Verbatim wording from the response “The following long-term safety improvements were agreed to proceed and be implemented by Southwark as part of the Denmark Hill town centre upgrade project (during 2017-18), subject to design, feasibility and safety audit:” Source location 2017-0052-Response-by-Southwark-Council
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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 Changes affecting the Strategic Route Network require TfL approval and cannot be implemented unilaterally.
Verbatim wording from the response “Denmark Hill is also part of the designated Strategic Route Network (SRN) in London. This means that although Southwark is the Highway and Traffic Authority for this area that it must notify TfL of any proposals which may have an impact on the Strategic Route Network. TfL must give approval to any such proposals before they can be implemented. As such, any changes to road design in this area cannot be made unilaterally if they may impact on the SRN, which anything altering the traffic flow along Denmark Hill may do.” Source location 2017-0052-Response-by-Southwark-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The proposed interim sign could not be installed because no suitable location existed given the bus stops and pelican crossing.
Verbatim wording from the response “The sign proposed in the long-term solution was considered as an interim option but, unfortunately, there were no suitable locations to site the sign due to the current positions of the bus stops and the pelican crossing.” Source location 2017-0052-Response-by-Southwark-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations