11 Dec 2024 Fehim AHMET · Prevention of Future Deaths report Inner North London
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Concerns raised 4 Lack of estate-agent guidance on action regarding particular property hazards View source Failure to record reported tenant access to hazardous property areas View source Failure to transfer property-hazard information to changing tenants View source Failure to follow up reported tenant access to hazardous property areas 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
Fehim AHMET · 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
Fehim Ahmet was sitting in a café when a man fell through a skylight from the flat roof above and struck him. He died a fortnight later from his injuries; concerns included the lack of guidance for estate agents about recording and passing on hazards, and the failure to follow up reports that tenants were accessing the roof.
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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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of estate-agent guidance on action regarding particular property hazards
Wider context from the report “1. I heard at inquest that, as industry standard, there is no requirement or even guidance regarding action to be taken by estate agents about particular property hazards , say noting on the property file to warn tenants about a flat roof that is easily accessible via a window but is not in fact safe to access. Such information is not automatically passed on when tenants change and is not necessarily enshrined in the tenancy agreement.
2. In this instance the café owner downstairs had rung the estate agent to complain about tenants from the upstairs flat being on the roof of the café and it was reported there were emails about this, but nobody from the estate agency had made a note or followed up with the tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to record reported tenant access to hazardous property areas
Wider context from the report “1. I heard at inquest that, as industry standard, there is no requirement or even guidance regarding action to be taken by estate agents about particular property hazards, say noting on the property file to warn tenants about a flat roof that is easily accessible via a window but is not in fact safe to access. Such information is not automatically passed on when tenants change and is not necessarily enshrined in the tenancy agreement.
2. In this instance the café owner downstairs had rung the estate agent to complain about tenants from the upstairs flat being on the roof of the café and it was reported there were emails about this, but nobody from the estate agency had made a note or followed up with the tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer property-hazard information to changing tenants
Wider context from the report “1. I heard at inquest that, as industry standard, there is no requirement or even guidance regarding action to be taken by estate agents about particular property hazards, say noting on the property file to warn tenants about a flat roof that is easily accessible via a window but is not in fact safe to access. Such information is not automatically passed on when tenants change and is not necessarily enshrined in the tenancy agreement .
2. In this instance the café owner downstairs had rung the estate agent to complain about tenants from the upstairs flat being on the roof of the café and it was reported there were emails about this, but nobody from the estate agency had made a note or followed up with the tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up reported tenant access to hazardous property areas
Wider context from the report “1. I heard at inquest that, as industry standard, there is no requirement or even guidance regarding action to be taken by estate agents about particular property hazards, say noting on the property file to warn tenants about a flat roof that is easily accessible via a window but is not in fact safe to access. Such information is not automatically passed on when tenants change and is not necessarily enshrined in the tenancy agreement.
2. In this instance the café owner downstairs had rung the estate agent to complain about tenants from the upstairs flat being on the roof of the café and it was reported there were emails about this, but nobody from the estate agency had made a note or followed up with the tenants .
” Open source report
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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 incident falls outside the enforcement powers applicable to the relevant property management or letting agent and landlord.
Verbatim wording from the response “I would explain that our team’s remit is to enforce the Estate Agents Act 1979 and the Tenant Fees Act 2019.” Source location Response from National Trading Standards
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 Housing, health and safety, fire, and environmental health authorities should address the relevant safety concerns.
Verbatim wording from the response “We would recommend that you contact the Local Authority Housing team, The Health and Safety Executive, the Fire Service and the Local Authority Environmental Health team.” Source location Response from National Trading Standards
Open published response
29 Mar 2023 Angela Jean Kearn · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to provide sufficiently prominent warnings about full-face mask risks to affected users View source Lack of medical-profession awareness and training on Immersion Pulmonary Oedema View source Failure of mask safety testing to replicate general-public use conditions View source Lack of applicable standards for full-face snorkelling masks 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
Angela Jean Kearn · 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
Angela Jean Kearn, aged 63, collapsed and died while snorkelling in Egypt on 13 January 2020. The inquest identified immersion pulmonary oedema as the cause of death, with hypertension, hormone replacement therapy and use of a full-face snorkel mask each contributing more than minimally. Concerns included limited medical awareness of immersion pulmonary oedema and insufficiently publicised safety warnings about using full-face snorkel masks with cardiovascular or respiratory conditions.
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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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently prominent warnings about full-face mask risks to affected users
Wider context from the report “ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner.” The same additional wording is being translated and added to all websites of the company.
x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions.
xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks . Those purchased before 2017 had no warning in relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified .
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of medical-profession awareness and training on Immersion Pulmonary Oedema
Wider context from the report “Awareness of Immersion Pulmonary Oedema in the medical profession:
i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training , as a consequence, it can be missed by those treating the condition and is often mistaken for drowning.
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Failure of mask safety testing to replicate general-public use conditions
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask.
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public .
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time.
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of applicable standards for full-face snorkelling masks
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask .
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public.
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time .
” Open source report
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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 Office for Product Safety and Standards holds responsibility for product recalls and consumer product safety matters.
Verbatim wording from the response “National Trading Standards (NTS) is not able to act on the issues raised in this report. NTS is a grant giving body that utilises Government grants to commission specified elements of Trading Standards related work from local authorities. Product safety does not fall within the scope of NTS. We do not receive any grants to commission work in this area. Issues surrounding product recalls and the Government lead for the safety of consumer products lies with the Office for Product Safety and Standards (part of the Department for Business and Trade). They work with local authorities on product recalls and we would recommend that, if it has not already been sent to them, that this report is sent to the Chief Executive of OPSS to respond.” Source location Response from National Trading Standards
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 Product safety falls outside the organisation’s functions and grant-funded scope, so it cannot act on the reported issues.
Verbatim wording from the response “National Trading Standards (NTS) is not able to act on the issues raised in this report. NTS is a grant giving body that utilises Government grants to commission specified elements of Trading Standards related work from local authorities. Product safety does not fall within the scope of NTS. We do not receive any grants to commission work in this area. Issues surrounding product recalls and the Government lead for the safety of consumer products lies with the Office for Product Safety and Standards (part of the Department for Business and Trade). They work with local authorities on product recalls and we would recommend that, if it has not already been sent to them, that this report is sent to the Chief Executive of OPSS to respond.” Source location Response from National Trading Standards
Open published response
30 Sep 2019 Owen Carey · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of statutory requirements for the appearance of restaurant allergen notices View source Lack of complete allergen information on the face of restaurant menus View source Lack of a national register of severe food anaphylactic reactions View source Inadequate allergen training for serving staff View source Insufficient prominence of allergen notices on restaurant menus View source See 2 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
Owen Carey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 22 April 2017, Owen Carey ate food at Byron restaurant at the O2 centre despite making serving staff aware of his dairy allergy. The chicken contained buttermilk, causing a severe food-induced anaphylactic reaction from which he died. Concerns included the adequacy of allergen training, the prominence and effectiveness of allergen notices and information on menus, and the absence of a national register for severe food anaphylactic reactions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory requirements for the appearance of restaurant allergen notices
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of complete allergen information on the face of restaurant menus
Wider context from the report “(3) The lack of key allergen information on the face of restaurant menus and therefore their potential to be falsely reassuring: In my findings I concluded that Owen and his brother would have been falsely reassured with the menu description of Owen's order because on its face the Byron O2 menu in place at the time did not readily identify that the chicken would have been marinated in buttermilk or at all. I was shown a more up to date menu from Byron O2 and note that where buttermilk is now used to marinate chicken it is identified. However, the prompt for this change was one of ‘food fashion’ I was told rather than a move to make the menu more allergen friendly. Although I accept that triggering a discussion between a customer and member of serving staff about allergens is of key importance (as indicated above), the absence of any simple allergen words or symbols on the face of a restaurant menu is of concern , particularly when one takes into account (i) what I was told about the latest figures demonstrating how a significant proportion of customers may be naturally shy/ reluctant about sharing their allergies with serving staff and (ii) that restaurants, like Byron O2, tend to attract younger diners dining alone (i.e. school age children without their parents). It also concerns me that at the time there were symbols on the menu depicting the use of peanuts, but not other allergen , which in my view could also have potentially falsely reassured diners that allergens were being identified on the face of the menu when in fact they were not .
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of a national register of severe food anaphylactic reactions
Wider context from the report “(4) The lack of a national register recording severe food anaphylactic reactions: I was told in evidence that despite faster ambulance response times, a greater awareness of allergies and a greater distribution of epi-pens that the death rate for severe food anaphylaxis remains static and that this is attributed in part to the fact that little is known about these deaths because thus far there has been a failure to collect together any learning from these tragedies . It concerns me that there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists .
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Inadequate allergen training for serving staff
Wider context from the report “(1) The adequacy and effectiveness of allergen training at Byron O2: My findings included that there must have been a human error by a member of Byron O2 serving staff at the point of ordering. The training provided to serving staff regarding allergens at Byron O2 was limited to a combination of staff members simply attesting to the fact that they had read the company's training on allergen information and no more, coupled with an “on the job” induction in respect of which no records or details existed. It was accepted in evidence that Byron O2 had a high turnover of serving staff. This, I was told and accept, is common for the restaurant industry overall, who often rely, for example on seasonal workers. I was not confident that the current approach to allergen training about which I heard evidence was effective and / or would engage the less diligent employee , which any organisation will have, and which are potentially in a greater proportion where there is high staff turnover.
” 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 National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Insufficient prominence of allergen notices on restaurant menus
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” Open source report
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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 Food Standards Agency is responsible for allergen legislation, policy and managing national food incidents.
Verbatim wording from the response “It seems however that the concerns you raise relate to the underpinning statutory system, in particular the lack of statutory requirements in relation to the notification of allergens in the circumstances that Mr Carey purchased his food and also the lack of a national register of such incidents. I see that your letter was also sent to the Food Standards Agency. The FSA have the responsibility, on behalf of Government, for the legislation and policy relating to allergens and for managing national food incidents so I am sure they will be well placed to address the issues you have raised.” Source location 2019-0335-Response-by-National-Trading-Standards
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 Local authorities are responsible for food safety enforcement in their respective areas.
Verbatim wording from the response “As such the activities relating to the regulation of food safety in general, and allergens in particular, do not fall within our remit. At a local level this responsibility lies with individual local authorities. NTS is not an overseeing body for local authorities. Each local authority is responsible for the level of food safety enforcement it undertakes in its own area.” Source location 2019-0335-Response-by-National-Trading-Standards
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 Food safety and allergen regulation do not fall within the respondent’s remit.
Verbatim wording from the response “As such the activities relating to the regulation of food safety in general, and allergens in particular, do not fall within our remit. At a local level this responsibility lies with individual local authorities. NTS is not an overseeing body for local authorities. Each local authority is responsible for the level of food safety enforcement it undertakes in its own area.” Source location 2019-0335-Response-by-National-Trading-Standards
Open published response
3 Jul 2017 Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report North Yorkshire (West)
View report summary
Concerns raised 1 Lack of chair sensors to detect a foot in the mechanism 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
Joseph Francis De Pellegrino-Farrugia · 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
Joseph Francis De Pellegrino-Farrugia, a 92-year-old man with dementia, was injured when his foot became trapped in the mechanism of his electric reclining chair during a transfer to a commode. He sustained crush injuries and ongoing ulceration and necrosis of his left great toe, and died at home on 20 December 2016; the injury contributed to his death. Evidence raised concern that the chair lacked sensors to detect and release a trapped foot.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Trading Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of chair sensors to detect a foot in the mechanism
Wider context from the report “Evidence was heard to the effect that the chair was not fitted with sensors which would have detected the presence of the foot in the mechanism to prevent the crushing injury and to release the foot.
” 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