Dear Coroner

Response to Regulation 28: Prevention of Future Deaths Report

I write in response to the Regulation 28 Report to Prevent Future Deaths [‘PFD report’] you issued following the inquest touching the death of Liam Allan.

The London Fire Brigade [‘LFB’] was not an interested person in the proceedings to investigate the circumstances of Mr Allan’s death. It has not been possible to ascertain the evidence presented to you during the course of this inquest.

Set out below are actions taken by LFB in relation to the matters of concern raised in your PFD report. These do not take account of any material you may have heard during the course of the inquest touching Mr Allan’s death.

Radio communications

Following recommendations of the Grenfell Tower Inquiry in respect of radio communications at incidents, LFB has made significant changes to its radio system - Airwave Digital Main-Scheme Radio system. The changes improved communications between emergency services on incident grounds. This enables greater interoperability of the different operational talk systems used by the Metropolitan Police Service [‘MPS’] and LFB.

In late 2022, further improvements to sharing of electronic incident records by emergency services came through the introduction of the Multi Agency Incident Transfer [‘MAIT’] System. MAIT allows emergency services control rooms to share incident data electronically. LFB along with the MPS are upgrading their systems to accommodate this. However robust radio communications between control rooms are currently in place to share incident information via a secure radio network.

Emergency service control rooms have the capability to talk directly to each other. This is done in accordance with a memorandum of understanding signed by all London Emergency Service Control Rooms for swift passage and sharing of incident information. This direct communication between control rooms is done via a dedicated airwave talk group channel

Both the MPS and LFB are progressing the ability to exchange this information electronically. Whilst that work continues, the fastest way for the MPS to request the resources of the LFB at an incident is through a dedicated telephone line or via the dedicated airwave channel.

Water safety

Water safety along the Thames is an important part of the broader prevention work at LFB, in discharging its obligations under the Fire and Rescue Services Act 2004.

Currently LFB chairs the Tidal Thames Water Safety Forum. The Brigade also sits on the London Water Safety Partnership. Membership of these bodies provides LFB with the means to participate in and influence improvements in safety of persons in the vicinity of the Thames and other waterways in London.

LFB has worked with London Local Authorities to support them installing throwline boards at multiple points along the River Thames. Each throwline board contains a thowbag and foil blanket. These boards not only contain rescue equipment but provide precise geolocation detail, which can be used by LFB control staff to dispatch crews in the event of an incident.

The need for additional throwline boards along the Thames is regularly reviewed.

Since Mr Allan’s death in August 2022, LFB has undertaken a number of activities aimed at improving safety along the River Thames. These include the following:

1. Working with London Local Authorities to help ensure the proper installation of water safety equipment at key points, linked to emergency services control rooms.

2. On 25th July 2023 – World Drowning Prevention Day - writing to Chief Executives of all London Local Authorities urging a review of water rescue equipment and arrangements. Several water safety events were held on this day at venues including Teddington lock, Hampton Court Palace and Hampton canoe club.

3. On 20th September 2023 an additional 10 throwline boards was installed in the vicinity of the point where Mr Allan drowned in Kingston-upon-Thames. In partnership with the London Boroughs of Richmond-upon-Thames and Kingston-upon-Thames, over 34 throwline boards have been installed along the Thames.

4. In the Richmond and Kingston areas of the Thames, as part of borough partnership initiatives in 2023/24, LFB provided throwlines and training in their use, to businesses, cafes, bars and restaurants along the river. Training in throwline use has also been provided to parks patrols.

5. In July 2024 a water safety room was opened at Twickenham Fire Station to provide training and education for river safety. The opening was covered by the broadcast media.

6. A number of multi-agency training exercises have been held to test and improve the emergency response on the Thames.

7. LFB has strengthened its operational working with Surrey Fire and Rescue Service to improve the response to emergencies on the Thames.

8. In May 2024, LFB Control had added details of water rescue resources held by neighbouring Fire and Rescue Services. This allows control room operators so assess whether LFB resources could be nearer to an incident and deployed more quickly if needed.

9. From February 2025, LFB Control staff monitor ES3 channel - the Coastguard channel - and broadcast any incident on the Thames to which LFB can respond.

I hope this response provides you with the necessary assurance that LFB is working to address the matters raised in your report.

Dear Dr Anton Van Dellen Thank you for raising the concern in relation to the death of Liam Stephen Allan on 26 August 2022. It is with great sadness that I read about the circumstances of his death. The National Fire Chiefs Council (NFCC) is committed to a culture of learning and improvement and seeks to support fire and rescue services to embed a learning culture. We actively track Prevention of Future Deaths reports that relate to fire and rescue services or similar relevant activities such as emergency response driving and share them with our members to ensure all opportunities to improve are taken. In your report you have identified NFCC as being an organisation that has the power to take action to prevent future deaths associated with delays in control rooms transferring information between agencies via the telephone rather than using a CAD-mediated system to transfer information electronically. We recognise the seriousness and devasting impact that can occur from ineffective and untimely sharing of information between emergency services. This has been captured within the Fire Control Fire Standard which requires fire and rescue services in England to provide fire control employees with effective systems and arrangements to mobilise appropriate resources and share incident related information with operational employees, other fire controls and other organisations. To support this further, effective working with partner agencies is a critical part of our Fire Control Guidance. This includes multi-agency hazards and control measures on the following:
• Ineffective communication between fire control and other agencies
• Inaccurate situational awareness during a multi-agency incident: Fire Control
• An uncoordinated response to a multi-agency incident: Fire Control
• Learning in isolation from other agencies: Fire Control One of the control measures is to establish effective communication systems between fire control and other agencies. Within this guidance it gives several strategic actions including

Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46

the consideration of configuring mobilising systems to integrate with electronic methods of communication. This will take a variety of forms within fire and rescue services and be agreed locally with their relevant partners. There is a Multi-Agency Information Transfer (MAIT) system that can be used by UK fire controls and partner agencies. This system provides a method for organisations to share incident information electronically and is currently being implemented in all fire control rooms in England. It will enable interoperability between different systems and facilitate electronic information exchange between fire control rooms. This system could, therefore, facilitate electronic information exchange between emergency control rooms of all responding agencies should they sign-up also. We seek to support fire and rescue services to improve the effectiveness and maximise the use of digital systems and this is key priority for us in the Fit for the Future strategic plan, which was developed in partnership with the Local Government Association and National Employers (England). This has led to the development of various pieces of guidance and tools on our Digital, Data and Technology webpages, and we continue to look at how we can influence innovation across the UK fire and rescue community. For this tragic death of Liam Stephen Allan, we have been in liaison with London Fire Brigade to ensure that all learning captured from the incident is processed through our NFCC Organisational Learning arrangements. By doing this, we will not only be able to share key learning points with other UK fire and rescue services, but we will also be able to reflect on national guidance to ensure that fire and rescue services are adequately addressing the risks of similar incidents from occurring.

Dear Dr Van Dellen, Liam Stephen Allan (Deceased) Case 25548493 Thank you for your letter dated 23 April 2025 and the enclosed Regulation 28 Report following the inquest into the tragic death of Liam Stephen Allan. The London Borough of Barking and Dagenham (LBBD) wishes to express its condolences to Mr Allan's family and acknowledges the important matters raised in the Prevention of Future Deaths Report_ We are committed to ensuring that action is taken to mitigate future risks associated with our riverside and watercourse areas Current Position LBBD acknowledges its responsibilities from both riparian landowner and various health and safety perspectives. While the Borough currently implements a general duty of care across its open spaces and water-adjacent areas, we acknowledge the need for a coordinated and risk- based approach to identifying and mitigating foreseeable dangers. Planned Actions We will be undertaking the following steps as part of our proactive response: Comprehensive Survey and Asset Mapping A Borough-wide survey of all waterbodies and riverside locations will be initiated to: Identify current locations and conditions of buoyancy aids, signage, fencing, and other safety infrastructure. Highlight gaps or deteriorated assets that require immediate or future attention This task will be coordinated by our Drainage Engineer; working in conjunction with other LBBD landowners and service departments, to ensure all relevant areas (including Parks, Housing, and Highways) are assessed. 2 Risk Assessment Criteria Each water-adjacent site will be assessed using the following criteria: The nature of the watercourse (e.g, depth, flow physical hazards)_ WWW lbbd gov.uk disability INVESTORS IN PEOPLE' WWW_ facebook com/barkinganddagenham confident EMPLOYER We invest in people Gold @Ibbdcouncil rate,

Barking Dagenham Public access levels and demographics (e.g , areas used by children or school groups) Visibility and accessibility for rescue operations_ Presence of hazards such as steep banks, culverts, weirs, or areas with difficult egress: Known areas with historical incidents or near misses, to the extent that this data is accessible. 3_ Standardisation ot Safety Equipment Following the assessment: We will install or upgrade buoyancy aids in high-risk locations, prioritising high- traffic public access areas. Aids will be clearly marked with reflective white stripes or similar enhancements to improve visibility in low light: Consideration will be given to the lighting of buoyancy aids, especially in locations used during evening hours or with known low visibility Inspection and Maintenance Regime Once installation and upgrades are complete, a structured inspection and maintenance programme will be implemented to: Ensure ongoing functionality and visibility of equipment Replace damaged or missing assets promptly. Timetable Survey and asset mapping to commence by July 2025_ Risk assessments and recommendations expected by October 2025. Installation/upgrades and inspection regime to follow in late 2025, subject to resource availability. Cross-Agency and Emergency Communication Issues While our Borough does not manage emergency communications between the Metropolitan Police Service and the London Fire Brigade , we strongly support improvements in this area. will work with the Local Resilience Forum and relevant partners to advocate for enhanced inter-agency communication, particularly in critical response scenarios We trust the above addresses the concerns outlined in your report: We remain committed to ensuring the safety of our communities and welcome any further input from your office.

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Dear Sir, Madam,

Inquest: Liam Stephen Allan, Deceased. D.O.D 27 August 2022

We are in receipt of the HM Coroners Prevention of Future Death Report (“the Report”) in relation to Mr Liam Allan, deceased, case 25548493. I note you have sent the report to all London boroughs with Thames River frontage. Other boroughs will have inland waterways, parks with lakes and rivers and other sections of rivers and streams under their ownership as land or riparian owner. I note you did not send the report to the Port of London Authority (PLA), who are responsible for river safety generally, or the Royal National Lifeboat Institute, who have a presence on the River Thames and respond to emergency incidents, or the Coastguard. A few years ago the PLA set up the Tidal Thames Water Safety Forum. You may wish to consider sending the Coroner’s report to that group. For the reasons given below the London Borough of Havering (“the Council”) is not a member. As you go toward central London from the east, along the River Thames, the environment changes from that in Havering to continuous sections of Thames Path and public space next to the river. In Havering there are relatively short sections of accessible Thames Path (neither council owned nor highway maintained at public expense), private wharfs and built up industrial areas. There are no bridges or river crossings over / under the Thames in Havering’s part of East London. It is noted the Coroner has referenced three Matters of Concern which I address in turn below.
1. Inadequate Lighting of Buoyancy Aids

Head of Highways, Traffic and Parking

Telephone: 01708 433769 email: Textphone: 01708 433175

Date: 23 June 2025

As far as my enquiries have determined, the Council does not own any Thames Riverside buoyancy aids. The provision, maintenance and any lighting of buoyancy aids will often fall to riparian land owners. The Council does own inland bodies of water and publically accessible places next to these. Consideration and review of risk assessments as to the provision of life buoys at these sites was recently given. Further consideration as to the lighting of these will now be given and this will be completed within three months of this letter. The report findings will be reviewed as part of risk assessment processes going forward. The report findings have also been shared with known riparian owners in case they have publically accessible lifesaving equipment.
2. White Stripes Applied to Buoyancy Aids to increase visibility Whenever the Council procures new buoyancy aids we will ensure the purchase is as per the relevant British Standard foremost and the application of a white stripe(s) will be required.
3. Communications between Emergency Services We consider this to be a matter for the emergency services to address. For this reason, no action by the Council is proposed. In addition to our response to your Matters of Concern above we will also ensure all relevant departments within the Council are made aware of your Report. As part of the review of the Local Plan, the Local Planning Authority will consider whether there is scope to include a policy for developers developing land adjacent to water to provide and maintain lifesaving equipment, so as to secure incremental improvements wherever possible.