PFD report

Alexander Adnan Cardoza · Prevention of Future Deaths report

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Issued 3 Apr 2025•City of London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised5

  1. Failure of barriers to prevent surmounting
    Part of recurring concern: Inadequate physical barriers preventing access to dangerous drops or areas
  2. Barrier design incorporating horizontal metal wiring that may assist surmounting
    Part of recurring concern: Inadequate physical barriers preventing access to dangerous drops or areas
  3. Absence of CCTV security camera monitoring
    Part of recurring concern: Insufficient CCTV monitoring of access to high-risk locationsPart of recurring concern: Unreliable safety CCTV monitoring systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 of barriers to prevent surmounting

Wider context from the report

“1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

Open source report

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

Barrier design incorporating horizontal metal wiring that may assist surmounting

Wider context from the report

“1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

Open source report

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

Absence of CCTV security camera monitoring

Wider context from the report

“1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

Is this part of a recurring concern?

Yes — Insufficient CCTV monitoring of access to high-risk locations; Unreliable safety CCTV monitoring systems.

Open source report

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

Insufficient operational security to prevent barrier surmounting and falls

Wider context from the report

“1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 movable objects being used to assist barrier surmounting

Wider context from the report

“1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025. 3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying. 4. I am particularly concerned that, despite previous knowledge of the risks, (i) the barriers in place ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place. ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

Open source report
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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