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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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 Fire Brigade; 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 Fire Brigade; 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
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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 Upgrade LFB and MPS systems to exchange incident information electronically through MAIT.
Verbatim wording from the response “In late 2022, further improvements to sharing of electronic incident records by emergency services came through the introduction of the Multi Agency Incident Transfer ['MAIT'] System. MAIT allows emergency services control rooms to share incident data electronically. LFB along with the MPS are upgrading their systems to accommodate this. However robust radio communications between control rooms are currently in place to share incident information via a secure radio network.” Source location Response from London Fire Brigade
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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 Existing direct radio communications between emergency service control rooms provide a robust means of sharing incident information while electronic exchange develops.
Verbatim wording from the response “In late 2022, further improvements to sharing of electronic incident records by emergency services came through the introduction of the Multi Agency Incident Transfer ['MAIT'] System. MAIT allows emergency services control rooms to share incident data electronically. LFB along with the MPS are upgrading their systems to accommodate this. However robust radio communications between control rooms are currently in place to share incident information via a secure radio network.” Source location Response from London Fire Brigade
Open published response
3 Oct 2024 Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report East London
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Concerns raised 4 Failure to leave or share written fire risk management plans with relevant recipients View source Failure to convey home fire safety findings to responsible carers View source Absence of a risk management plan to reduce fire harm View source Failure to enquire into the outcome of home fire safety visits 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
Mrs Gabrielle Sarah Anne Steel · 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
Mrs Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.
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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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to leave or share written fire risk management plans with relevant recipients
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check .
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to convey home fire safety findings to responsible carers
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her .
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Absence of a risk management plan to reduce fire harm
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel . Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire into the outcome of home fire safety visits
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit , so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Review Home Fire Safety Visit booking questions to identify in-home care and recommend that carers attend visits.
Verbatim wording from the response “LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.” Source location Response from London Fire Brigade
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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 Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
Verbatim wording from the response “Noting HM Coroner's observations, we have started to review our processes and have engaged with our Information Management Team to discuss the data protection issues around sharing information with third parties where the resident has full mental capacity. LFB are reviewing the data protection privacy impact assessment and consulting the Information Commissioner to fully scope how we can best meet this need while ensuring privacy for the resident.” Source location Response from London Fire Brigade
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 Scope options for leaving bespoke fire-safety information with residents, family members or carers, engaging other fire services to identify best practice.
Verbatim wording from the response “LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.” Source location Response from London Fire Brigade
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 Update Home Fire Safety Visit policy, guidance and staff training where necessary following the process review.
Verbatim wording from the response “Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.” Source location Response from London Fire Brigade
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 Existing policy authorises sharing advice only with a resident who can understand and retain it, so staff followed the correct process.
Verbatim wording from the response “Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person. Providing staff are satisfied that the individual recipient is able to understand and retain the advice given, they share advice and observations face to face. During the booking of Mrs Steel's Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and retain the information provided – this was noted on our records and therefore the crews followed the correct process as outlined in the policy.” Source location Response from London Fire Brigade
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 Care providers are responsible for planning and delivering care based on risk assessments, including assessing and mitigating fire risk.
Verbatim wording from the response “The Fire Service's statutory role does not include responsibility for a resident's care plan or for making or contributing to a personalised risk management plan for an individual resident. Home Fire Safety Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the resident. Care providers are regulated to plan and deliver care based on risk assessments, and this should include assessing risk from fire. A care provider should not need an HFSV to prompt attention on any of the points raised above. However, we accept that there is learning around communication with the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set out above that we are taking steps to explore improvements.” Source location Response from London Fire Brigade
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 statutory fire service role does not include responsibility for an individual resident’s care plan or personalised risk management plan.
Verbatim wording from the response “The Fire Service's statutory role does not include responsibility for a resident's care plan or for making or contributing to a personalised risk management plan for an individual resident. The purpose of a Home Fire Safety Visit is to provide advice and guidance to help keep the resident safe. At a Home Fire Safety Visit, LFB staff record advice given on a data collection form which is then uploaded into a database. In most cases this information is recorded using a tablet which will populate the database automatically. Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person and currently no functionality to be able to leave a copy of the findings with the resident.” Source location Response from London Fire Brigade
Open published response
18 Jan 2024 Name not published · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure to request an appropriately extended height ladder appliance at the outset of incidents involving a person on a roof View source Delays in LFB attendance at incidents involving a person on a roof 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
Name not published · 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
████████ jumped from the roof of his block of flats at 5.33pm on 26 July 2023, following a delay in the attendance of the London Fire Brigade and the provision of an extended height ladder appliance. The principal concern was that the appliance may not have been requested from the outset, despite the call relating to a person on the roof of a block of flats.
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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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to request an appropriately extended height ladder appliance at the outset of incidents involving a person on a roof
Wider context from the report “1. ████████ rang police at 4.33pm, exactly one hour before he actually jumped off the roof. Police attended immediately and sought firefighter assistance immediately. However, they reported to me at inquest that there was some delay in the attendance of LFB.
2. Upon attendance, firefighters recognised that their ladders would not reach the roof of the flats and so called for an extended height ladder appliance . This had to travel from further afield and ████████ became more agitated during the wait. It had not arrived at 5.33pm when he jumped.
The police were especially concerned that the extended height ladder appliance had not been requested from the outset , given that the call was in respect of a person on the roof of a block of flats.
I did not take evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am unaware.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Delays in LFB attendance at incidents involving a person on a roof
Wider context from the report “1. ████████ rang police at 4.33pm, exactly one hour before he actually jumped off the roof. Police attended immediately and sought firefighter assistance immediately. However, they reported to me at inquest that there was some delay in the attendance of LFB .
2. Upon attendance, firefighters recognised that their ladders would not reach the roof of the flats and so called for an extended height ladder appliance. This had to travel from further afield and ████████ became more agitated during the wait. It had not arrived at 5.33pm when he jumped.
The police were especially concerned that the extended height ladder appliance had not been requested from the outset, given that the call was in respect of a person on the roof of a block of flats.
I did not take evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am unaware.
” Open source report
9 Mar 2023 Mr Tomas Ceida · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to follow up non-receipt of a building application View source Lack of assurance that fire safety and evacuation responsibilities are competently adopted and implemented View source Lack of communication with fire enforcement during site construction and events View source Failure to notify London Fire Brigade of a material discrepancy from the planning application View source Lack of public and future contractor awareness of fire precaution processes and duties View source Failure to create or retain documentation of changes in contractor and site manager roles 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
Mr Tomas Ceida · 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
Mr Tomas Ceida died in hospital after a fire at a site being used as a nightclub, where construction work was underway and staff and operatives sometimes slept overnight. The jury identified concerns including the unsuitable acoustic wall, unsafe and inadequately supervised hot works, and failures to agree and communicate fire-safety responsibilities, provide adequate fire alerts, conduct an orderly evacuation, and complete adequate fire-risk assessments. The coroner also raised concerns about regulatory follow-up, communication between authorities, documentation of contractor roles, and public and contractor awareness of fire-safety duties.
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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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up non-receipt of a building application
Wider context from the report “• RLBG Building Control were aware of the composition of the acoustic wall compacted with hay or straw, and its fire risks and did not follow up the non-receipt of a building application after March 2013 .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that fire safety and evacuation responsibilities are competently adopted and implemented
Wider context from the report “• Although steps were taken by JHS to mitigate fire risks through the subsequent management and supervision of hot works, there is no evidence of what steps are taken by JHS individuals now in the building trade in each case to ensure the responsibility for fire safety and evacuation has been competently adopted and implemented .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Lack of communication with fire enforcement during site construction and events
Wider context from the report “• LFB visited the site in 2014 and the local team attended large night club events on the site, during construction from 2016, but there was no communication with fire enforcement
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to notify London Fire Brigade of a material discrepancy from the planning application
Wider context from the report “• RLBG Planning Division did not notify London Fire Brigade in 2016 when discovered that the wall was not a living wall as envisaged in the planning application .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Lack of public and future contractor awareness of fire precaution processes and duties
Wider context from the report “• It is understood that changes in the law and duties of securing general fire precautions has changed since the fire. It is not clear that the public and future contractors are necessarily aware of the processes and duties. The coroner is concerned whether there is a lack of public awareness, which may be a risk to future deaths. This is brought to the attention of the HSE and LFB as enforcement authorities.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to create or retain documentation of changes in contractor and site manager roles
Wider context from the report “• JHS were initially documented as principal contractor and its subcontractor as site manager in 2016, but either did not create or did not retain documentation of the alleged change of role before the date of the fire , from discussions with the leaseholder of the site, who was the client.
” 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 Continue community engagement and media campaigns promoting general fire safety precautions.
Verbatim wording from the response “To meet its obligations under the Fire and Rescue Services Act 2004, LFB has dedicated departments dealing with community and statutory fire safety matters. These teams continue to actively engage with local communities to promote fire safety awareness i.e. general fire safety precautions. The Brigade conducts fire safety campaigns in the media and will work to ensure that these continue, with the aim of raising the level of fire safety awareness in the general public.” Source location Response from London Fire Brigade
Open published response
26 Apr 2022 Ashlie Timms · Prevention of Future Deaths report East London
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Concerns raised 7 Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre View source Lack of clear practical guidance for managing high-risk electrical devices in specialist housing View source Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres View source Incomplete fire safety audit processes View source Lack of clear guidance on fitting digital key-pad locks in specialist housing View source Failure of fire safety audits to accurately assess compliance View source Failure to ensure staff competence in fire evacuation procedures View source See 4 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
Ashlie Timms · 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
Ashlie Timms, a 46-year-old woman living in supported accommodation, died on 20 April 2018 after a fire started when fabric materials came into contact with a portable fan heater. Staff delayed calling the emergency services, did not evacuate her, and the fire safety arrangements, alarm system, evacuation procedures and door lock were identified as concerns.
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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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre
Wider context from the report “2. Fire Alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard Guidance , which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Lack of clear practical guidance for managing high-risk electrical devices in specialist housing
Wider context from the report “4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres
Wider context from the report “6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Incomplete fire safety audit processes
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on fitting digital key-pad locks in specialist housing
Wider context from the report “5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing .
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure of fire safety audits to accurately assess compliance
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance . These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire . The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff competence in fire evacuation procedures
Wider context from the report “1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation . Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm .
” Open source report
22 Feb 2021 Jaden Matthew FRANCOIS-ESPRIT · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to recognise firefighters’ deteriorating mental ill health View source Failure to explore requests for help followed by refusal of help 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
Jaden Matthew FRANCOIS-ESPRIT · 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
Jaden hanged himself at home on either 25 or 26 August 2020, after becoming increasingly withdrawn and feeling isolated. The principal concern was that his deteriorating mental wellbeing was not recognised by colleagues, so he was not offered psychological counselling or other support. Other concerns included difficulties related to dyslexia, workplace treatment, and the need for a fuller understanding of station culture and Jaden’s experiences.
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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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise firefighters’ deteriorating mental ill health
Wider context from the report “I heard at inquest that the London Fire Brigade has quite sophisticated systems in place to support firefighters suffering mental ill health. However, Jaden was not offered the support of, for example, psychological counselling, because it was not appreciated that he was so very low.
Obviously if firefighters are to be given the best chance of recovering from mental ill health, their difficulties first need to be recognised.
I appreciate that it can be difficult to detect that a person may be depressed or exceptionally unhappy. Signs may be subtle and require a nuanced approach.
• Jaden often complained that he was bored because Wembley Green Watch had not been called to many incidents. I heard evidence that boredom in a new firefighter can be quite common. However, I also heard that a complaint of boredom can be a sign of a person with dyslexia avoiding an unpalatable or daunting task.
• Jaden had dyslexia and was worried that he would not be able to complete his written work in order to become a fully qualified firefighter, yet the reality was that his station officer was fully aware of his difficulties and had tried to reassure Jaden that he was certainly capable of achieving his goal.
• He did need extra time, the space to make mistakes and a degree of sensitivity that was not always afforded him. On the other hand, he asked for help and was given a mentor, but did not make use of him and so eventually the mentorship ceased. That request for help followed by a refusal of help was not explored. Such an exploration might have led to a greater understanding of how Jaden could be helped.
• Jaden felt he was being treated unfairly at work and his family have formed the view that there was an element of racism there, driven in part by their belief that Jaden was the only non white person on Wembley Green Watch. Yet the reality was that he joined a watch where a quarter of the firefighters were people of colour.
• He described being teased about bringing chicken, rice and peas to work to eat, thinking that this teasing was because the food was Caribbean. Looking at this from the outside, chicken, rice and peas seems a dish without obvious world origin. Moreover, I heard about a huge variety of food being brought to work by firefighters, with some even weighing their food before eating. None of this sits easily with a dish of chicken, rice and peas resulting in a racist comment.
Jaden’s interior life did not always accord with what was going on around him. Most of all he felt isolated, and yet it was clear to me that there was a lot of affection for him at the fire station. He did not always feel comfortable there. It is not necessarily an easy task to unearth such feelings in a colleague but, if it results in such a tragedy as this being avoided, it is a worthwhile one.
” 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 Fire Brigade; that does not assign responsibility.
PFD Monitor interpretation Failure to explore requests for help followed by refusal of help
Wider context from the report “I heard at inquest that the London Fire Brigade has quite sophisticated systems in place to support firefighters suffering mental ill health. However, Jaden was not offered the support of, for example, psychological counselling, because it was not appreciated that he was so very low.
Obviously if firefighters are to be given the best chance of recovering from mental ill health, their difficulties first need to be recognised.
I appreciate that it can be difficult to detect that a person may be depressed or exceptionally unhappy. Signs may be subtle and require a nuanced approach.
• Jaden often complained that he was bored because Wembley Green Watch had not been called to many incidents. I heard evidence that boredom in a new firefighter can be quite common. However, I also heard that a complaint of boredom can be a sign of a person with dyslexia avoiding an unpalatable or daunting task.
• Jaden had dyslexia and was worried that he would not be able to complete his written work in order to become a fully qualified firefighter, yet the reality was that his station officer was fully aware of his difficulties and had tried to reassure Jaden that he was certainly capable of achieving his goal.
• He did need extra time, the space to make mistakes and a degree of sensitivity that was not always afforded him. On the other hand, he asked for help and was given a mentor, but did not make use of him and so eventually the mentorship ceased. That request for help followed by a refusal of help was not explored. Such an exploration might have led to a greater understanding of how Jaden could be helped.
• Jaden felt he was being treated unfairly at work and his family have formed the view that there was an element of racism there, driven in part by their belief that Jaden was the only non white person on Wembley Green Watch. Yet the reality was that he joined a watch where a quarter of the firefighters were people of colour.
• He described being teased about bringing chicken, rice and peas to work to eat, thinking that this teasing was because the food was Caribbean. Looking at this from the outside, chicken, rice and peas seems a dish without obvious world origin. Moreover, I heard about a huge variety of food being brought to work by firefighters, with some even weighing their food before eating. None of this sits easily with a dish of chicken, rice and peas resulting in a racist comment.
Jaden’s interior life did not always accord with what was going on around him. Most of all he felt isolated, and yet it was clear to me that there was a lot of affection for him at the fire station. He did not always feel comfortable there. It is not necessarily an easy task to unearth such feelings in a colleague but, if it results in such a tragedy as this being avoided, it is a worthwhile one.
” 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