15 Mar 2024 Sydney Alex Piper · Prevention of Future Deaths report East London
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Concerns raised 3 Lack of policing of homeless encampments in wooded areas View source Lack of monitoring of homeless encampments in wooded areas View source Failure to adequately supervise vulnerable persons View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sydney Alex Piper · 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
Sydney Alex Piper, a 69-year-old man living in supported accommodation, left a mental health clinic while inadequately supervised on 23 February 2023 and was discovered deceased in a tent in Epping Forest on 24 March 2023. His death was caused by morphine toxicity, although it was not possible to determine how he was administered morphine or came to be at the site. The concerns were inadequate supervision of a vulnerable person and insufficient monitoring and policing of encampments, which increased the risk of fatal harm.
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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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Lack of policing of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately supervise vulnerable persons
Wider context from the report “1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.
I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.
” 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 Issue Community Protection Notices where appropriate and collaborate with police to enforce them when necessary.
Verbatim wording from the response “StreetLink, a platform that connects people sleeping rough to other agencies and charities, including St Mungo’s.
3.3. Where appropriate, Neighbourhood Officers can issue Community Protection Notices instructing individuals to move on. If necessary, they collaborate with local police to enforce these notices.
3.4. The Local Authority has a contract in place to cut back overgrown vegetation, particularly that which may attract rough sleepers.
3.5. Where land is owned by other parties, Neighbourhood Officers liaise with those landowners to ensure that appropriate action is taken.” Source location Response from London Borough of Waltham Forest
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 Monitor parks and open spaces through weekly contractor inspections, Park Officer inspections and Sports and Leisure referrals of rough-sleeping indicators.
Verbatim wording from the response “3. ROUGH SLEEPING
3.1. All parks and open spaces within the Local Authority’s remit are monitored as follows:” Source location Response from London Borough of Waltham Forest
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 Monitor commissioned supported-living provisions through annual quality-assurance visits, increased visits where improvement plans apply, and required-action reports.
Verbatim wording from the response “1.4. In terms of ongoing monitoring, the Quality Assurance monitoring team undertake at least one visit annually to all provisions in the Borough. Where concerns are identified and a service improvement plan has been implemented, the team will visit with greater frequency to support the improvement process. The provisions are monitored on a number of key areas: Staffing, Support/Care, Health and Safety, Policy and Procedure, Governance, Quality Assurance, Resident feedback, staff feedback, Medication Safeguarding and MCA/DoLs. A report is sent to the provider detailing actions required within a given timeframe.” Source location Response from London Borough of Waltham Forest
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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 Management and monitoring of the relevant Epping Forest land fell outside the Local Authority’s remit because the Corporation of London owned and managed it.
Verbatim wording from the response “The Local Authority does not own or manage the relevant part of Epping Forest or the surrounding land in this case. It is understood that the relevant land is owned and managed by the Corporation of London. However, we set out below how parks and open spaces within Local Authority remit are managed, as well as the safeguards in place for land owned and managed by third parties.” Source location Response from London Borough of Waltham Forest
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 Responsibility for commissioning and supervising the supported-living service rested with the NHS Trust, not the Local Authority.
Verbatim wording from the response “The Local Authority did not employ the support worker or commission the service that employed them in this case. We set out below the processes by which such services are monitored when commissioned by the Local Authority.” Source location Response from London Borough of Waltham Forest
Open published response
12 Jul 2022 Louise Asha Allen · Prevention of Future Deaths report East London
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Concerns raised 5 Non-comparable pay for care-coordinator posts View source Excessive caseloads for care co-ordinators View source Failure to provide continuity of care View source Insufficient number of care co-ordinators for clinical need View source High turnover of care-coordinator staff 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.
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AI-generated summary
Louise Asha Allen · 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
Louise Asha Allen, who had bipolar disorder and emotionally unstable personality disorder, was discharged from hospital in December 2020 and was regarded as a very high risk to herself. Between February and June 2021, she did not receive necessary mental state assessments or sufficient support, and inaccurate clinical details contributed to unreliable risk assessments. On 12 June 2021, she placed herself in front of a train. The principal concerns related to inadequate care coordination, including insufficient continuity of care, excessive caseloads, staff turnover and insufficient numbers of care coordinators.
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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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Non-comparable pay for care-coordinator posts
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Excessive caseloads for care co-ordinators
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuity of care
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation Insufficient number of care co-ordinators for clinical need
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” 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 Waltham Forest; that does not assign responsibility.
PFD Monitor interpretation High turnover of care-coordinator staff
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” 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