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PFD Report
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Ref: 2024-0031
All 1 response received
· Deadline: 14 Mar 2024
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56-Day Deadline
14 Mar 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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.
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.
Responses
The London Fire Brigade states that its internal inquiries provided information incongruous with the coroner's report. As they were not an Interested Person at the inquest, they request an extension and copies of inquest documents and audio recordings to formulate a proper response.
AI summary
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Dear Coroner
Prevention of Future Death Report: (died 26.07.23)
I write in response to your Regulation 28 report in the above case, which was received by LFB on 22nd January 2024.
To adequately respond to the concerns raised in your report, the London Fire Brigade [‘LFB’] has made extensive internal enquiries of officers involved in the incident that resulted in the death of
At this juncture, the information obtained from LFB personnel involved in the incident, appears incongruous with the actions noted in your report.
As HM Coroner will know, the LFB was not recognised as an Interested Person; indeed the LFB was unaware of the inquest taking place. HM Coroner noted in the Regulation 28 report: “I did not take evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am unaware.”
In the circumstances, and in order to enable a proper Regulation 28 response, the LFB requests the following: (i) An extension of 28 days (in the first instance) to respond to the Regulation 28 report; (ii) A copy of the Record of Inquest; (iii) A copy of the written disclosure made to the Interested Persons; (iv) A copy of the audio recording of the inquest.
I look forward to hearing from you.
Prevention of Future Death Report: (died 26.07.23)
I write in response to your Regulation 28 report in the above case, which was received by LFB on 22nd January 2024.
To adequately respond to the concerns raised in your report, the London Fire Brigade [‘LFB’] has made extensive internal enquiries of officers involved in the incident that resulted in the death of
At this juncture, the information obtained from LFB personnel involved in the incident, appears incongruous with the actions noted in your report.
As HM Coroner will know, the LFB was not recognised as an Interested Person; indeed the LFB was unaware of the inquest taking place. HM Coroner noted in the Regulation 28 report: “I did not take evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am unaware.”
In the circumstances, and in order to enable a proper Regulation 28 response, the LFB requests the following: (i) An extension of 28 days (in the first instance) to respond to the Regulation 28 report; (ii) A copy of the Record of Inquest; (iii) A copy of the written disclosure made to the Interested Persons; (iv) A copy of the audio recording of the inquest.
I look forward to hearing from you.
Report Sections
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.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.