30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
View report summary
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.
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 Westminster City Council; 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 Westminster City Council; 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
5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to consider documented pressure-ulcer risk when issuing care instructions View source Failure to adequately investigate safeguarding explanations and evidence View source Failure to implement system, training and partnership changes after safeguarding investigation View source Failure to involve district nursing team in discharge planning View source Failure to arrange pressure-relieving bed and mattress replacement before discharge View source Failure to provide required personal hygiene and catheter care during home visits View source Failure to issue and disseminate daily skin-integrity checking instructions to all carers View source Omission of daily skin-integrity checking instruction from discharge assessment form View source Failure to establish daily skin-integrity monitoring responsibility View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 8
Action
Continue working with partner agencies to build on current improvements and incorporate learning from the Safeguarding Adults Review.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Continue embedding discharge and coordinated-care improvements and reviewing practice with whole-person care central to changes.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Work with Kapital Care to support improvements in care practice, documentation, escalation and communication.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Review safeguarding-enquiry recommendations for lessons and improvements across relevant organisations.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source See 5 more actions
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AI-generated summary
Richard Thomas SHANNON · 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
Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider documented pressure-ulcer risk when issuing care instructions
Wider context from the report “5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions . She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately investigate safeguarding explanations and evidence
Wider context from the report “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement system, training and partnership changes after safeguarding investigation
Wider context from the report “8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months . The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place .
Apparently, no lessons have been learnt.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve district nursing team in discharge planning
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting , it is much more likely that this measure would have been considered.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report “3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction .
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice.
Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report “4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish daily skin-integrity monitoring responsibility
Wider context from the report “2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with partner agencies to build on current improvements and incorporate learning from the Safeguarding Adults Review.
Verbatim wording from the response “The local authority will continue working with partner agencies to build on the current improvements, which will be further informed by the outcome of the current Safeguarding Adults Review process.” Source location Response from City of Westminster
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Verbatim wording from the response “• Standard operating procedures are being updated to reflect the outcomes of the workshops. This includes:
◦ a training package for newly qualified social workers entering the service and for experienced social workers as part of their yearly appraisal and continuous professional development. The training package focuses on identifying care needs associated with pressure care, manual handling and equipment, medication, risk management plans and the co-ordination role of a social worker.
◦ an improved tool for discharge including a template checklist to ensure all key areas are addressed.
◦ key escalation points and links with community providers including District Nurses.” Source location Response from City of Westminster
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 Continue embedding discharge and coordinated-care improvements and reviewing practice with whole-person care central to changes.
Verbatim wording from the response “The authority is addressing the multiple actions required to improve hospital discharge and delivery of co-ordinated care. All future actions and learning arising from Professor Shannon’s death will be implemented with whole person care central to any changes. We are absolutely committed to maintaining and embedding those improvements already implemented, prioritising implementation of those in progress and consistently reviewing our practice.” Source location Response from City of Westminster
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 Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Verbatim wording from the response “• To support an all-agency approach to discharge planning, social workers now use a checklist to ensure that all aspects of the care plan have been actioned prior to discharge, e.g., equipment delivery, district nurse involvement, care agency fully briefed. This is to minimise the risk of there being any gaps in the discharge process across all agencies.” Source location Response from City of Westminster
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 Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.
Verbatim wording from the response “• The Safeguarding Service has revised its practice so that when reviewing cases in professional supervision, it will explore whether delegated or direct conversations should take place, factoring in whether there are conflicts of interest in individual agencies being asked to conduct parts of the safeguarding enquiry.” Source location Response from City of Westminster
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 the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Verbatim wording from the response “• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.” Source location Response from City of Westminster
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 Work with Kapital Care to support improvements in care practice, documentation, escalation and communication.
Verbatim wording from the response “• The local authority has worked with Kapital Care to support improvements in their practice, as detailed in Kapital Care’s response regarding their training, documentation, escalation to use if there is an issue, improved communication with District Nurses and others involved in a person’s care.” Source location Response from City of Westminster
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 Review safeguarding-enquiry recommendations for lessons and improvements across relevant organisations.
Verbatim wording from the response “• The London Multi-Agency Safeguarding Adults Policy requires all individual organisations to review the recommendations identified in the Section 42 Safeguarding Enquiry investigation report for any lessons to be learned. This has now taken place, but the delay is acknowledged and is a learning that will be addressed by all partners.” Source location Response from City of Westminster
Open published response
6 Jul 2015 John Paul Clarke · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure of highway inspections to identify missing road signs View source Failure of highway inspections to identify defective sign lighting View source Insufficiently comprehensive highway asset database View source Failure of the inspection system to facilitate remedial works for road-sign and lighting defects View source Failure to record highway signs in the inspection asset database View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Paul Clarke · 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
John Paul Clarke died on 5 March 2014 after his motorcycle contacted the raised kerb of a traffic island in London, causing him to fall and collide with a rigid metal Keep Left sign. The concerns included failures to identify a missing sign, defective lighting, and incomplete highway asset records, together with an inspection system that was not sufficiently effective to identify and remedy these defects.
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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of highway inspections to identify missing road signs
Wider context from the report “1. Westminster City Council in its capacity as the highways authority carried out monthly walked inspections of Northumberland Avenue (along with other inspections). These inspections did not register that a “Keep Left” sign located at the easterly end of the traffic island involved in the incident was missing and had been missing for at least three years.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of highway inspections to identify defective sign lighting
Wider context from the report “2. The various inspections carried out by Westminster City Council failed to register that the external lighting arrangement for the “Keep Left” sign that was located on the traffic island was defective and had probably not been working for three years.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiently comprehensive highway asset database
Wider context from the report “5. The database of street signs and other highway assets used by Westminster City Council as a basis for its periodic inspections was not sufficiently comprehensive.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the inspection system to facilitate remedial works for road-sign and lighting defects
Wider context from the report “4. The inspection system in force in the period 2011-2014 was not sufficiently effective to identify missing road signs and/or lighting defects which good practice required to be in place and to facilitate remedial works to rectify the situation.
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record highway signs in the inspection asset database
Wider context from the report “3. The missing “Keep Left” sign and the Keep Left sign which was in place at the western end of the traffic island, were not recorded on the database of assets used by Westminster City Council in the course of their inspections . This omission made it less likely that the defects referred to would be noticed and hindered any attempts to initiate remedial works.
” 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 Train inspectors on updated missing-asset works-order and inventory-reporting protocols.
Verbatim wording from the response “6.1 The user guide produced for the inspectors on the use of Confirm Connect is attached as Appendix 1. This is used as part of the inspector training, including induction for new staff, and has been updated to include the protocol for raising works orders when the asset is missing (page 32 for highways assets, page 56 for lighting assets and page 61 for gully assets).” Source location Response
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 Agree the scope and method for updating legacy scheme areas, including whether to resurvey them and use Confirm Connect.
Verbatim wording from the response “4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).” Source location Response
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 Monitor uncommitted works orders daily using a newly introduced Confirm report.
Verbatim wording from the response “2.9 Outstanding committed works orders issued to the service provider are monitored every day through a report generated from Confirm and at regular monitoring meetings. In certain circumstances works orders can become stuck and stay ‘uncommitted’ in the system. When this happens, the works order does not go through to the service provider. However, a new report has been introduced to allow staff and the provider to monitor these on a daily basis as well.” Source location Response
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 Provide additional regulatory-signage and TSRGD training to inspectors in January 2016.
Verbatim wording from the response “6.4 While the inventory holds the sign diagram number already and will be updated to give both the TSRGD diagram number and the description so the inspectors see this, given the latter will take some time to complete, additional training on regulatory signage and TSRGD is being provided to the inspectors in January 2016.” Source location Response
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 Complete physical inventory updates for outstanding legacy scheme areas by 31 March 2016.
Verbatim wording from the response “4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).” Source location Response
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 Replace illuminated-sign attributes with a handheld Sign Number and Description attribute, with rollout to non-illuminated signs if successful.
Verbatim wording from the response “3.4 With the move to handheld technology, a new attribute of Sign Number and Description has been added to enable site staff, including highways inspectors, to easily select the sign type by description without having to know the TSRGD ref number (Figure 2). The drop down menu has the TSRGD number at the end of the description. This will replace the two existing Illuminated sign attributes listed in paragraph 3.3. This is a work in progress and if successful, it will be rolled out to Highways non-illuminated signs as well (Figure 1).” Source location Response
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 Develop protocols enabling lighting crews to correct base inventory data during routine maintenance inspections.
Verbatim wording from the response “4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.” Source location Response
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 Confirm Connect for lighting maintenance to provide real-time inventory updates.
Verbatim wording from the response “4.2 There are two methods of updating the inventory. The first is using handheld units and this method updates the inventory for reactive and routine maintenance works carried out using the same Confirm Connect software as the inspectors. This is already used by our drainage provider and shortly will be used by our lighting service provider for both reactive and routine maintenance. This brings much greater opportunity to keep the inventory updated in real time.” Source location Response
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 Complete illuminated-asset inventory updates over two full maintenance inspection cycles by 31 March 2018.
Verbatim wording from the response “4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.” Source location Response
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 inspection, contingency and inventory systems ensure missing or incorrectly recorded assets generate remedial work and prompt database updates.
Verbatim wording from the response “The aim of the measures that the City Council already has in place, and those to be implemented, is that the City Council maintains an accurate inventory. The systems in place ensure that where an asset is missing or the record of it is incorrect, that the inventory database, contingency protocols and inspector knowledge and awareness ensure that the required remedial work is always ordered for our service provider to action and that the required update to the inventory database occurs promptly.” Source location Response
Open published response
20 Feb 2015 Maria Nekrasova · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Inadequate night-time lighting of the bridge carriageway View source Lack of prevention of pedestrian crossing of the bridge carriageway View source Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare View source Lack of protection for pedestrians in the middle of the bridge carriageway View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maria Nekrasova · 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
Maria Nekrasova was struck by a licensed taxi while standing in the hatched area in the middle of Westminster Bridge carriageway at about 1.50 am on 4 May 2014, sustaining a severe traumatic head injury from which she died. Concerns included the absence of pedestrian barriers or protection in the carriageway, low and contrasting street lighting, and vehicle headlight glare affecting drivers’ ability to see pedestrians.
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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate night-time lighting of the bridge carriageway
Wider context from the report “(2) At night the level of street lighting is low , the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness ;
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of prevention of pedestrian crossing of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation);
” 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare
Wider context from the report “(3) The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting 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 Westminster City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for pedestrians in the middle of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation) ;
” 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