7 Aug 2024 Malika HIBU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to make an identified unsafe barrier safer or secure its remediation View source Failure to risk assess the canal barrier View source Failure to consider barrier safety during housing development planning View source Failure to act on resident complaints about the barrier View source Lack of knowledge of the ownership boundary View source Inadequate canal-side railing protection for children and adults View source See 3 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Malika HIBU · 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
Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.
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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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make an identified unsafe barrier safer or secure its remediation
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer .
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess the canal barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal ;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider barrier safety during housing development planning
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development .
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on resident complaints about the barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier ;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the ownership boundary
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished ;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate canal-side railing protection for children and adults
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it .
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Require project-specific waterfront water-safety reviews using the RoSPA risk-rating tool in new-property procedures.
Verbatim wording from the response “(iii) A Design Governance Panel reviews whether proposed schemes meet five Design Priorities. Safety is one of those five priorities. Proximity to open water was previously assessed as part of that priority where relevant. Since the inquest, proximity to open water and risk mitigation is now explicitly referenced. Accordingly, risk assessment of new waterfront properties on a project-by-project basis included specific review of water safety and, since the inquest, this has now been specifically codified in our procedures to require a water safety review applying the RoSPA risk rating tool. Such reviews consider, for example, the installation of railings, use of boundary markers and lighting, incorporation of signage, water safety education, and systems for site monitoring, as appropriate.” Source location Response from Peabody Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install and maintain temporary canal-side fencing inspected by RoSPA.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
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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 Conduct an estates audit and develop a group Water Safety Policy with RoSPA to tailor water-risk assessment guidance.
Verbatim wording from the response “16. In addition, in accordance with advice from RoSPA, an audit is being conducted across Peabody estates to inform the formation of a Water Safety Policy across the group to ensure that water risk assessment guidance is properly tailored to the needs of our organisational context. Work on this document is already under way in co-operation with the RoSPA, and we plan to finalise this policy following completion of work on the Employer’s Requirements.” Source location Response from Peabody Trust
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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 Require explicit water-adjacency and similar-hazard risk assessments, design reviews, mitigation planning and post-installation inspections in design guidance and contractor requirements.
Verbatim wording from the response “15. While robust risk assessment and management procedures identified above are already in place within Peabody, we keep our practices under regular review and have considered further insight from the tragic incident in February 2024. We are therefore updating our Design Guide and our Standard Employer’s Requirements for contractors to include, as a check-list item, an explicit requirement to conduct risk assessments of adjacency to water and similar hazard types from the design stage onwards. This will reference a requirement for both a design review of proposals and planned risk mitigation, and also a post-installation inspection. We plan to finalise and embed these changes within the Employer’s Requirements by 31 January 2025.” Source location Response from Peabody Trust
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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 Work with relevant parties to approve, design, construct and implement a permanent canal-edge protective barrier.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
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 improvements to complaints systems, processes and culture mean no additional changes to the complaints system and processes are currently required.
Verbatim wording from the response “21. In this case, therefore, there was a formal complaints processing system in place, but this issue was not further actioned for the reasons stated above. We are satisfied that the various improvements we have made to our complaints systems, processes and culture since 2019 (both to comply with the Housing Ombudsman Code and to reflect our own learning) mean that no additional changes are required to our complaints system and processes at this point. However, we are strengthening our processes for near miss/hazard reporting (see below).” Source location Response from Peabody Trust
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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 Installing new protective railings requires approval and changes to legal agreements involving the London Borough of Islington and CRT/CIC.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
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 Peabody sought the Council’s assistance because it understood the Council or CRT/CIC held responsibility for the barrier and Dock Wall.
Verbatim wording from the response “(iii) The walls bounding the water along this part of the Basin had been leased to the Council and the Council was required to keep all of the walls, without any division of particular parts, in good repair. We understand that this suggests ownership of those walls was retained by CIC under the 2015 Transfer.” Source location Response from Peabody Trust
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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 Peabody considered it unable to block or alter the barrier because it lacked ownership rights and understood planning conditions prohibited obstructing waterfront access.
Verbatim wording from the response “20. No formal enquiries or complaints were submitted by residents in relation to the safety of the canal side barrier at Crest Buildings. We understand however that, in 2019, an informal concern was raised about the barrier to the then Neighbourhood Manager on a routine site visit. The then Neighbourhood Manager considered that it was not possible to block off the canal side barrier in view of what was understood about the planning conditions, the policy of the Council to maintain open access to the waterfront, and Peabody’s lack of ownership rights over the barrier. We understand that it is because she considered no action was possible and the concern was raised informally in the course of a site visit when various other enquiries and issues will also have been raised, that the issue as to the barrier was not formally logged for processing on the CRM system.” Source location Response from Peabody Trust
Open published response
8 Jan 2021 Elizabeth PAMMENT · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to communicate and record emergency contact instructions for alarm monitoring staff View source Failure to review and improve emergency procedures after a serious incident View source Failure to obtain and record personalised emergency contact instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth PAMMENT · 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
Elizabeth Pamment lived in sheltered accommodation and died from pneumonia after two falls on the same night, the second leaving her alone on the floor until she was found the following morning. The principal concerns were that Peabody had not recorded or communicated an agreed instruction to contact her nearby daughter during an emergency, and had no protocol for recording or sharing such instructions with the alarm monitoring service.
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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and record emergency contact instructions for alarm monitoring staff
Wider context from the report “When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff.
Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this.
The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell.
Peabody staff explained the following in evidence.
1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family.
2. There was no Peabody protocol for the taking and recording such an instruction.
3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member.
4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment.
5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures.
If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review and improve emergency procedures after a serious incident
Wider context from the report “When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff.
Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this.
The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell.
Peabody staff explained the following in evidence.
1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family.
2. There was no Peabody protocol for the taking and recording such an instruction.
3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member.
4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment.
5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures.
If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort.
” 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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and record personalised emergency contact instructions
Wider context from the report “When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff.
Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this.
The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell.
Peabody staff explained the following in evidence.
1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family.
2. There was no Peabody protocol for the taking and recording such an instruction.
3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member.
4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment.
5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures.
If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort.
” 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 Amend Careline information sharing and produce a standard Resident Information Form capturing consent, special instructions and emergency next-of-kin arrangements.
Verbatim wording from the response “In order to address the concern raised, we have amended how we share residents’ information with Islington Telecare to ensure that any specific requests are captured with the resident’s permission and noted to the Careline provider. We have also included a section that explains to the resident that if the resident is alerted out of hours and the call requires an emergency response then the Careline provider will always contact their NOK unless the resident specifically opts out of that procedure.” Source location 2021-0006-Response-from-Peabody-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet Islington Telecare and other Careline providers to review and standardise information forms and procedures, incorporating learning from the incident.
Verbatim wording from the response “Our service manager has made arrangements to meet all other careline providers we commission to review the other forms in use to see if they could be improved. The outcome of those discussions will further inform our procedural review.” Source location 2021-0006-Response-from-Peabody-Redacted
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 Implement a procedure to ask residents about contact instructions, review existing records, and log and share special arrangements with relevant Careline providers.
Verbatim wording from the response “As per the previous action above, we will now always use a comprehensive form to exchange essential information with Careline providers and this will include any special instructions from the resident.” Source location 2021-0006-Response-from-Peabody-Redacted
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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 prior review identified no specific procedural or staff failings, and family concerns were not known until the inquest.
Verbatim wording from the response “We were not aware of the concerns raised by the family until our attendance at the inquest and our own review had not identified any specific procedural or staff failings. Previous incidents had also not highlighted gaps in our practice.” Source location 2021-0006-Response-from-Peabody-Redacted
Open published response
24 Jul 2014 Graham Darby · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to clearly flag direct suicide threats to agencies responsible for housing and eviction 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
Graham Darby · 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
Graham Darby, who had alcohol dependence, was found dead at his home the day after being evicted and forcibly re-entering the property; the inquest concluded that the cause of death was suspension by ligature and that his death was a suicide. A significant concern was that a reported threat to take his own life using a knife and rope if evicted was not passed on to the housing agency, and was therefore not sufficiently flagged between agencies.
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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 Peabody Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly flag direct suicide threats to agencies responsible for housing and eviction
Wider context from the report “That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction . This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted . The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances.
” 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