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
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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× 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 Kensington and Chelsea; 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 Kensington and Chelsea; 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
29 Apr 2019 Georgia Sylvia Nelson · Prevention of Future Deaths report Inner West London
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Concerns raised 6 Lack of suitable housing for young patients with severe and enduring mental illness View source Failure to use inpatient opportunities to address care and treatment needs before discharge View source Failure to ensure proper discharge planning and referral for patients with mental illness View source Severe shortage of rehabilitation housing placements View source Lack of long-term supported housing placements for patients with severe and enduring mental illness View source Failure to actively consider rehabilitation as a discharge option where housing concerns exist View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Refer clients needing long-term or lifelong supported housing to the funding and placement panel for evidence-based multidisciplinary decisions on commissioned support and accommodation.
View source
Action
Work with partner organisations to identify ongoing local rehabilitation needs and potential service developments for closer-to-home mental health rehabilitation placements.
View source
Action
Organise and use regular placement, provider and partnership meetings to assess demand, identify service gaps and inform housing support commissioning.
View source
Action
Continue multidisciplinary work with health and social care partners to assess mental health support and accommodation needs through the monthly placement panel.
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AI-generated summary
Georgia Sylvia Nelson · 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
Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.
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 Royal Borough of Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable housing for young patients with severe and enduring mental illness
Wider context from the report “1. That there is no suitable housing specifically for young patients with severe and enduring mental illness in RBKC .
” 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 Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Failure to use inpatient opportunities to address care and treatment needs before discharge
Wider context from the report “5. That whilst mental health patients are in hospital all opportunities are used to improve their care and treatment and that where possible, they are not discharged before these have been appropriately addressed , rather than discharging them as soon as they are deemed no longer at active risk to themselves or others .
” 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 Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper discharge planning and referral for patients with mental illness
Wider context from the report “4. That there should be a system to ensure that there is proper discharge planning and referral on for all patients discharged after admission with mental illness .
” 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 Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of rehabilitation housing placements
Wider context from the report “3. There is a severe shortage of rehabilitation housing placements in RBKC for patients who require them .
” 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 Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term supported housing placements for patients with severe and enduring mental illness
Wider context from the report “2. There are no long term placements, potentially life long, for any patients requiring supported housing in RBKC with such mental illness .
” 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 Kensington and Chelsea; that does not assign responsibility.
PFD Monitor interpretation Failure to actively consider rehabilitation as a discharge option where housing concerns exist
Wider context from the report “6. That rehabilitation should be more actively considered as a discharge option for patients especially where there are pre-admission concerns about their housing .
” 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 Refer clients needing long-term or lifelong supported housing to the funding and placement panel for evidence-based multidisciplinary decisions on commissioned support and accommodation.
Verbatim wording from the response “We would like to take the following action when addressing the prevention of future deaths. If the client may need long term or life long supported housing, the case will be brought to the funding and placement panel to decide what kind of long term or life-long support and accommodation will be commissioned through an evidence-based assessment by the” Source location 2019-0140-Response-by-RBKC_Redacted
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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 partner organisations to identify ongoing local rehabilitation needs and potential service developments for closer-to-home mental health rehabilitation placements.
Verbatim wording from the response “As part of the review, the two CCG’s, RBKC, Westminster City Council and CNWL are all working together to identify and explore any on-going needs and service developments within the local areas which may arise from this. We all recognise the need to move service users closer to their homes for mental health rehabilitation placements, to ensure better connections are maintained with family, friends, and local mental health services that can support service users on discharge. This is in line with best practice guidance, working collaboratively to align with GP practices, health and support services, and existing accommodation pathways across both boroughs, to create smoother step-down and step-up transitions for people and contributing to a better experience and outcomes for service users. The focus will be on improved quality and best value across the partnership.” Source location 2019-0140-Response-by-RBKC_Redacted
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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 Organise and use regular placement, provider and partnership meetings to assess demand, identify service gaps and inform housing support commissioning.
Verbatim wording from the response “We would like to offer you this joint response, to outline where the Housing Department, Adult Social Care and West London Commissioning Group colleagues, in partnership with Central North West London Trust, can work together to influence some of the changes you seek from your concerns. As part of the broader commissioning of services, we would like to strengthen the following regular partnerships meetings to look at need and demand, to support what services are jointly or singularly commissioned within the borough along with development of specifications to ensure key outcomes such as tenancy sustainment and the performance of the providers in enabling resident to be independent where possible is managed and monitored in each of the services. This is done through formal contract monitoring arrangements and placement review processes which are set out below: -” Source location 2019-0140-Response-by-RBKC_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue multidisciplinary work with health and social care partners to assess mental health support and accommodation needs through the monthly placement panel.
Verbatim wording from the response “Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.” Source location 2019-0140-Response-by-RBKC_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 Existing commissioned housing and support options, assessed through multidisciplinary panels, are considered adequate despite no dedicated service for young patients.
Verbatim wording from the response “Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.” Source location 2019-0140-Response-by-RBKC_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 Where suitable local services are unavailable, specialist housing and rehabilitation placements will be purchased outside the borough.
Verbatim wording from the response “Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.” Source location 2019-0140-Response-by-RBKC_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 Council disputes that RBKC has a severe shortage of rehabilitation housing placements, citing 707 supported-accommodation units and ongoing capacity reviews.
Verbatim wording from the response “In RBKC we currently have 707 units providing supported accommodation to people with a range of mental health needs, each with an individualised support plan which would include rehabilitation to enable people to develop greater independence. This would include, for example, developing daily living skills, managing medication, accessing specialist services, budgeting, managing own tenancies, developing peer relationships and accessing universal services including training and getting back into employment. This is supported by the key workers along with Community Mental Health Teams, through a process of reviews and assessments. Within our offer, we do not consider there is a severe shortage, but we recognise the need to continually assess demand and capacity, which we do through the various placement boards and project groups.” Source location 2019-0140-Response-by-RBKC_Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations