PFD report

Elsie Gibson · Prevention of Future Deaths report

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Issued 21 Oct 2013•South 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
3

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

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Concerns and recipient responses

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Report evidence summary

Concerns raised3

  1. Failure to maintain contemporaneous records of inspections
  2. Failure to take enforcement action against persons erecting scaffold towers without a licence
  3. Delays in investigating reported incidents involving unlicensed scaffold towers
    Part of recurring concern: Inadequate safety incident investigations
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 to maintain contemporaneous records of inspections

Wider context from the report

“Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities. When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest. I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated. As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured. I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities. ”

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 take enforcement action against persons erecting scaffold towers without a licence

Wider context from the report

“Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities. When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest. I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated. As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured. I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities. ”

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

Delays in investigating reported incidents involving unlicensed scaffold towers

Wider context from the report

“Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities. When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest. I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated. As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured. I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Official responses located
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Data last updated 7 September 2026

No official response is included in the current published snapshot.