PFD report

Sandra Elizabeth SENIOR · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 4 Mar 2024•Inner North 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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised2

  1. Failure of the front entrance access-control system to secure and permit controlled entry
    Part of recurring concern: Unreliable access controls for residential accommodation
  2. Failure to secure the secondary access barrier against unauthorised entry
    Part of recurring concern: Unreliable access controls for residential accommodation
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Maintain a specific contract for repairing communal door-entry systems when faults occur.

    Stated by London Borough of CamdenStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  2. Action

    Remove the communal entrance door’s latch and hook to prevent it being held open.

    Stated by London Borough of CamdenStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Inspection frequency cannot be increased because the caretaking service’s frequency is determined by available resources.

    Stated by London Borough of CamdenUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 the front entrance access-control system to secure and permit controlled entry

Wider context from the report

“The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time. The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. ”

Is this part of a recurring concern?

Yes — Unreliable access controls for residential accommodation.

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 secure the secondary access barrier against unauthorised entry

Wider context from the report

“The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door ████████, which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access ████████ ████████.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign████████, it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building ████████ was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building ████████ were not working effectively at that time. The concern is that it appears that the safety systems in place to stop unauthorised access ████████, in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. ”

Is this part of a recurring concern?

Yes — Unreliable access controls for residential accommodation.

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

Maintain a specific contract for repairing communal door-entry systems when faults occur.

Verbatim wording from the response

“On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.”

Source location

Response from Camden Council
Page 1 · response
Published 14 March 2024

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

Remove the communal entrance door’s latch and hook to prevent it being held open.

Verbatim wording from the response

“On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.”

Source location

Response from Camden Council
Page 1 · response
Published 14 March 2024

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

Inspection frequency cannot be increased because the caretaking service’s frequency is determined by available resources.

Verbatim wording from the response

“The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service.”

Source location

Response from Camden Council
Page 1 · response
Published 14 March 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Install an additional Fire Brigade lock requiring a different key on the rooftop exit.

    Stated by London Borough of CamdenStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.

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 an additional Fire Brigade lock requiring a different key on the rooftop exit.

Verbatim wording from the response

“For the roof top exit we have installed an extra “Fire Brigade” lock that requires a different key. It is unfortunately the case that suited keys that are used by the London Fire Brigade, and our maintenance teams, can be procured by members of the public who wish to access restricted areas (for example for recreational use or pirate radio station broadcasts). This can lead to roof top exits, or doors to machinery and intake cupboards, being left open at times. Hopefully the addition of this further lock will deter casual access.”

Source location

Response from Camden Council
Page 1 · response
Published 14 March 2024

Open published response
Back to top

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

Official responses located
1/1

Data last updated 7 September 2026