Arezou Tirgari · Prevention of Future Deaths report

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Issued 3 Jul 2023•City of London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to prevent persons being able to jump from the roof terrace

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. LS One New Change Limited

    Install approximately 2.5-metre-high hoarding across the terrace entrance until permanent works are completed.

  2. LS One New Change Limited

    Re-program the scenic lifts to restrict access to level 6 and align access with Madison’s opening hours.

  3. LS One New Change Limited

    Conduct an ongoing review of roof-terrace safety and apply lessons learned to maintain ONC safety.

  4. LS One New Change Limited

    Conduct planning and stakeholder engagement to develop permanent terrace safety works and submit the required planning application.

  5. LS One New Change Limited

    Close the public roof terrace until further notice.

  6. LS One New Change Limited

    Set aside capital funding for the future permanent safety works.

  7. LS One New Change Limited

    Appoint a project team to design, procure, administer and provide specialist advice for the permanent terrace works.

  8. LS One New Change Limited

    Position a security officer outside the scenic lifts to engage with visitors and explain the terrace closure.

  9. LS One New Change Limited

    Position two security officers between the entrance barriers from midday to midnight daily.

  10. LS One New Change Limited

    Install two lines of Tensabarriers across the terrace entrance.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. LS One New Change Limited

    The measures taken are considered sufficient to prevent people climbing the perimeter wall.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. LS One New Change Limited

    It is stated that visitors to One New Change face no risk from the roof terrace perimeter wall.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to prevent persons being able to jump from the roof terrace

Wider context from the report

“1. Kai Cheng Barnaby, Deceased, whose death is being investigated by HM Senior Coroner for Inner South London, jumped to his death on the 6th April 2023 from the roof████████. 2. Eight weeks later, on the 1st June 2023, Arezou Tirgari was also able to jump to her death from the same location. 3. It seems that no or no sufficient action has been taken to prevent persons being able to jump from the roof terrace and that there is an ongoing risk of further deaths. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 approximately 2.5-metre-high hoarding across the terrace entrance until permanent works are completed.

Verbatim wording from the response

“19. In addition, Landsec has appointed a team to design and install a hoarding approximately 2.5 metres in height across the terrace in the current location of the Tensabarriers. Following advice from Landsec’s structural engineers and its fabrication team, this hoarding is due to be installed in early September 2023. It is to remain in situ until the permanent works (discussed below) are completed which is estimated between April and June 2024.”

Source location

Response from Landsec
Page 4 · response
Published 7 July 2023

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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

Re-program the scenic lifts to restrict access to level 6 and align access with Madison’s opening hours.

Verbatim wording from the response

“• The two scenic lifts were re-programmed:”

Source location

Response from Landsec
Page 3 · response
Published 7 July 2023

Open published response

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 ongoing review of roof-terrace safety and apply lessons learned to maintain ONC safety.

Verbatim wording from the response

“26. Landsec is a company that had a sensible and considered risk management system in place at the time of the incident. Since this incident, we are conducting a review of the safety of the roof terrace, learning lessons, and using resources to ensure that ONC is a safe and enjoyable place to visit.”

Source location

Response from Landsec
Page 5 · response
Published 7 July 2023

Open published response

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 planning and stakeholder engagement to develop permanent terrace safety works and submit the required planning application.

Verbatim wording from the response

“20. Since Ms Tirgari’s death Landsec has held planning meetings with the City of London’s planning team, including the Planning and Development Director, the Senior Planning Officer and the Senior Public Health Practitioner. A pre-planning application meeting with the City of London is being sought for September 2023 and, subject to the outcome of that meeting, a full planning application will be submitted in October 2023, with works estimated to be completed between April and June 2024.”

Source location

Response from Landsec
Page 4 · response
Published 7 July 2023

Open published response

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

Close the public roof terrace until further notice.

Verbatim wording from the response

“18. Immediately after the incident on 1 June 2023, the following additional preventative measures were implemented in addition to those listed at paragraph 14 above:”

Source location

Response from Landsec
Page 3 · response
Published 7 July 2023

Open published response

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

Set aside capital funding for the future permanent safety works.

Verbatim wording from the response

“21. At the time of writing, I can confirm that the proposed permanent works are currently at the design stage and no final decisions have yet been made. However, capital has been set aside to ensure sufficient funding of the future works. Landsec are currently exploring a number of options such as the installation of a frameless and transparent glazed, cantilevered screen (approximately 2000mm high) which will span the entire length of the public roof terrace. The screen will be set back from the existing perimeter wall by a minimum of 600mm to enable cleaning on both sides of the glazing.”

Source location

Response from Landsec
Page 4 · response
Published 7 July 2023

Open published response

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

Appoint a project team to design, procure, administer and provide specialist advice for the permanent terrace works.

Verbatim wording from the response

“22. To assist in the design, Landsec has appointed the following project team:”

Source location

Response from Landsec
Page 4 · response
Published 7 July 2023

Open published response

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

Position a security officer outside the scenic lifts to engage with visitors and explain the terrace closure.

Verbatim wording from the response

“• One Landsec security officer was positioned outside the scenic lifts on the ground floor from 07:00 to 00:00/midnight to engage with public and advise why the terrace is closed.”

Source location

Response from Landsec
Page 4 · response
Published 7 July 2023

Open published response

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

Position two security officers between the entrance barriers from midday to midnight daily.

Verbatim wording from the response

“18. Immediately after the incident on 1 June 2023, the following additional preventative measures were implemented in addition to those listed at paragraph 14 above:”

Source location

Response from Landsec
Page 3 · response
Published 7 July 2023

Open published response

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 two lines of Tensabarriers across the terrace entrance.

Verbatim wording from the response

“18. Immediately after the incident on 1 June 2023, the following additional preventative measures were implemented in addition to those listed at paragraph 14 above:”

Source location

Response from Landsec
Page 3 · response
Published 7 July 2023

Open published response

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 measures taken are considered sufficient to prevent people climbing the perimeter wall.

Verbatim wording from the response

“3. Landsec is grateful for the opportunity to comment and contribute to the efforts that seek to prevent future tragedy. The purpose of this statement is to provide information on the arrangements in place at the time of Ms Tirgari’s death and changes made subsequently. We wish to assure the Learned Coroner that sufficient action has been taken to prevent persons being able to climb the perimeter wall and that there is no risk to any persons who visit ONC.”

Source location

Response from Landsec
Page 1 · response
Published 7 July 2023

Open published response

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

It is stated that visitors to One New Change face no risk from the roof terrace perimeter wall.

Verbatim wording from the response

“3. Landsec is grateful for the opportunity to comment and contribute to the efforts that seek to prevent future tragedy. The purpose of this statement is to provide information on the arrangements in place at the time of Ms Tirgari’s death and changes made subsequently. We wish to assure the Learned Coroner that sufficient action has been taken to prevent persons being able to climb the perimeter wall and that there is no risk to any persons who visit ONC.”

Source location

Response from Landsec
Page 1 · response
Published 7 July 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026