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
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
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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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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
9 Mar 2023 Mr Tomas Ceida · Prevention of Future Deaths report Inner South London
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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
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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 Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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 Royal Borough of Greenwich; 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 Identify and carry out planning compliance checks for repeated non-compliance and high-risk, high-footfall buildings or operations.
Verbatim wording from the response “In addition to information cascaded through the mechanisms of Integrated Enforcement , Planning Enforcement are committed to identify where compliance checks are necessary through their investigation processes. Compliance checks will be carried out where repeated non-compliance has been identified and where there is high risk buildings or operations with heavy footfall such as nightclubs or places of worship. Officers are now able to raise concerns relevant to LfB through the Integrated Enforcement initiative.” Source location Response from Royal Borough of Greenwich
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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 Operate the Integrated Enforcement Initiative to share information and review licensed-premises activity across council services and external enforcement partners.
Verbatim wording from the response “The council established an Integrated Enforcement Initiative in 2018 which pulls from all services with enforcement powers, it meets weekly and shares information between internal departments within the council including Licensing , Planning , Building Control , Environmental Health and external partners including the Police and Safer Neighbourhoods Teams and LfB. This information sharing group reviews amongst other things the operational activities of licensed premises such as Studio 338 and inspections made can identify areas of concern which may not otherwise be apparent to officers with relevant powers to regularise.” Source location Response from Royal Borough of Greenwich
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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 There was no statutory or procedural duty to notify the Fire Brigade after the planning inspection.
Verbatim wording from the response “The Fire Brigade was not notified following the inspection made on 25th July 2016 when it was discovered the sound wall had not been constructed in accordance with the permission granted in 2013 for a living wall with irrigation system but in fact what existed was a wall covered in plastic grass, officers were unaware of the composition as it was not visible to them. Not notifying LFB was not a failing or a disconnect in the service, there is not a statutory or procedural duty to do so.” Source location Response from Royal Borough of Greenwich
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7 Oct 2016 Dr Debatra Sircar · Prevention of Future Deaths report Inner South London
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Concerns raised 3 Lack of an interim care plan for patients pending Mental Health Act assessment View source Failure to assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment View source Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment 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
Dr Debatra Sircar · 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
Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.
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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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Lack of an interim care plan for patients pending Mental Health Act assessment
Wider context from the report “2. In the intervening 11 day period there was an absence of an interim care plan , identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period.
” 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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment
Wider context from the report “2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period .
” 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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment
Wider context from the report “1. He was at risk from falls, associated with his alcohol abuse and had frequently presented in A&E department with symptoms and injuries associated with intoxication. He was unfit to be treated in the community. There appeared to be no sense of urgency in securing a bed. He was booked for a Mental Health Act (MHA) Assessment 11 days after it was advised he needed hospitalization , by which time he had died. The court was informed the delay related to the unavailability of a local authority MHA practitioner.
” Open source report
19 Aug 2016 Amanda Coppen · Prevention of Future Deaths report Inner South London
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Concerns raised 3 Road layout misleading pedestrians and motorists about traffic direction View source Potential risk to schoolchildren from increased pedestrian use of junction View source Presence of ordinary traffic in the dedicated busway View source
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
Amanda Coppen · 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
Amanda Coppen suffered fatal injuries when she was struck by a bus while crossing Pilot Busway on 4 January 2016. The inquest evidence indicated that she was crossing on a signal-controlled pedestrian crossing when the signal was red to pedestrians and green to traffic. Concerns included the unusual road layout potentially misleading pedestrians and motorists, and a possible increased risk to schoolchildren following the construction of a nearby school.
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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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Road layout misleading pedestrians and motorists about traffic direction
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction . The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway . Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the road .
” 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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Potential risk to schoolchildren from increased pedestrian use of junction
Wider context from the report “I understand that a new school is shortly to be built close to this junction . This may increase the numbers of pedestrians using the junction and there is a potential risk to schoolchildren .
” 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 Royal Borough of Greenwich; that does not assign responsibility.
PFD Monitor interpretation Presence of ordinary traffic in the dedicated busway
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway , and pedestrians could be misled into looking the wrong way when crossing the road.
” 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 Implement the proposed dual-carriageway and bus-lane changes to the road layout at the earliest opportunity, subject to considering consultation responses.
Verbatim wording from the response “It is the practice of both TfL and Greenwich to undertake local public consultation on significant changes to their road networks. Consistent with those practices, a joint public consultation exercise is underway to seek public and stakeholder opinion on the conversion of the existing arrangement to a dual carriageway with bus lane provision.” Source location 2016-0299-Response-by-Transport-for-London
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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 Install a raised zebra crossing south of the junction to provide safer pedestrian routes between Millennium Village, the existing school, Pilot Busway and West Parkside.
Verbatim wording from the response “As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.” Source location 2016-0299-Response-by-Transport-for-London
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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 Complete feasibility work identifying conversion of the existing layout to a dual carriageway with bus lanes to address road-safety concerns.
Verbatim wording from the response “TfL and Greenwich have been working on developing a solution to address road safety concerns, arising from the unique nature of the road layout. We recognise that significant development is taking place in the area, including the construction of a new school, and that additional movements associated with those developments will increase concerns about road safety.” Source location 2016-0299-Response-by-Transport-for-London
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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 Introduce a 20-mile-per-hour speed limit with road markings and signage along Pilot Busway and West Parkside.
Verbatim wording from the response “As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.” Source location 2016-0299-Response-by-Transport-for-London
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 Improve junction signage and road markings to increase pedestrian awareness of oncoming traffic.
Verbatim wording from the response “As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.” Source location 2016-0299-Response-by-Transport-for-London
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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 pedestrian safety provisions, including footways and crossings, for the school expansion.
Verbatim wording from the response “TfL and Greenwich are also reviewing pedestrian safety provisions, including footway and crossings, which are to be provided as expansion of the school takes place.” Source location 2016-0299-Response-by-Transport-for-London
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations