Investigation and inquest
On 8 August 2023, I commenced an investigation into the death of ████████. The investigation concluded at the end of the inquest on 15 January 2024.
I made a determination at inquest of death by suicide. ████████ jumped from the roof of his block of flats at 5.33pm on 26 July 2023.
████████
Circumstances of the death
Before he jumped off the roof, ████████ called the Metropolitan Police Service (MPS), who in turn called the London Fire Brigade (LFB).
When police officers tried to negotiate with him, ████████ appeared receptive to the idea of coming down off the roof safely. Police officers were reluctant to suggest that he return the way he had come, as by now it was raining and they were concerned that he would slip, and so he waited on the roof for firefighters to escort him.
Coroner’s concerns
1. ████████ rang police at 4.33pm, exactly one hour before he actually jumped off the roof. Police attended immediately and sought firefighter assistance immediately. However, they reported to me at inquest that there was some delay in the attendance of LFB.
2. Upon attendance, firefighters recognised that their ladders would not reach the roof of the flats and so called for an extended height ladder appliance. This had to travel from further afield and ████████ became more agitated during the wait. It had not arrived at 5.33pm when he jumped.
The police were especially concerned that the extended height ladder appliance had not been requested from the outset, given that the call was in respect of a person on the roof of a block of flats.
I did not take evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am unaware.