Dear Coroner RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS: REGARDING THE DEATH OF ALEXANDER ADNAN CARDOZA INTRODUCTION
1.1 We confirm receipt of your report to prevent future deaths issued on 3 April 2025 (the ~Notice" ') , made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 following the death of Alexander Adnan Cardoza on 27 March 2025. A response is required by 29 May 2025 to deal with the concerns raised within the report
1.2 We would like to express our deepest sympathies to the family and friends of Alexander; following his untimely death.
1.3 This response is given as per the requirements under Regulation 29 of the Coroners (investigations) Regulations 2013_ THE NOTICE AND BROADER CONCERNS
2.1 We note the coroner has outlined the following concerns in the in the Notice. The barriers in place [remain surmountable; The barriers include horizontal metal wiring which; it appears, may assist the surmounting of the barrier; (iii) The an be moved and can be used to assist a person to surmount the barriers; City May

(iv) The nature and level of the operational security in place on the 27 March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and and There is no CCTV Camera monitoring
2.2 As such the coroner has requested that immediate action be taken to prevent future deaths by addressing the concerns set out above and that both Heron Property ad Samba are in position of power to take such action.
3. BACKGROUND AND PROPERTY INFORMATION
3.1 For ease of reference and to assist the coroner; we outline the position regarding the area of concern to the coroner.
3.2 the tenant for the operation of their business as a leased the premises in shell condition and completed their own full fit out: as full and sole responsibility for the operation of the business trading at the premises which includes including ensuring health and safety compliance.
3.3 are responsible for the management of the property including the structure and the barriers There are 34 Following the death of Alexander Adnan Cardoza are addressing the concerns raised by yourself at () and (ii) by demonstrating the primary actions being taken to alleviate those concerns The concerns raised at (iii), (iv) and (v) are within remit but we are working with to find an adequate and timely solution for the safe use of and outline our response to these concerns also_
3. Balustrade (referred t0 here as barrier(s)) heights within the built environment are governed and directed from Approved Document Part K of the Building Regulations, which stipulate that at any commercial or residential property, the barrier height shall be set at a minimum height of 1.lm from the finished floor level.
3.6 The original barriers on were over and above the building regulations compliance requirement of Llm at the time of practical completion: The barrier on the wwas extended to 2.4m by way of metal wires to prevent customers from dropping bver the side directly onto the pavement below. barrier was also increased to 2.4m by way of metal wires, following the death of Mr Hadgu: did not have these modifications made at the same time as the as beyond the Ithere is a flat roof preventing any dropped from falling to the ground: falling;

3.7 The Notice states, It seems that no or no sufficient action has been taken to prevent persons from able to fall from and this is "despite the subsequent structural and operational changes outlined in the inquest on 10 December 2024. As was submitted by the inquest; there were additional metal wires installed on as there had previously been installed on the 'urther; a full risk assessment was conducted by and this included information on the necessary operations of the Jincluding security and Unfortunately, it is evident these operational risk management controls were followed on the of 27 March 2025. The position is therefore, that had taken action following the inquest in December 2024 to further prevent persons from able to climb over and subsequently fall from
3.8 It is also respectfully noted that; in both incidents, individuals appear to have taken deliberate actions to bypass and surmount the barriers rather than having accidently fallen from them, as might be misconstrued from the above concern_
3.9 The metal wires currently re intentionally taut (i.e,, causing them to bend towards the direction of pull) so to make it harder; but not impossible to climb, however; it is understood by hat further preventative measures need to be taken to stop individuals from surmounting the barriers
3.10 For ease, we have dealt with the actions in response to the coroner's Notice in two parts, addressing each lindividually as different actions are taken in respect of each most appropriately deal with the risk presented. PROPOSED STRUCTURAL CHANGES
4.L has a boundary barrier comprising of glass with & stainless-steel frame at
1.39m high: There are additional metal wires to increase the height of the barrier to 2.4m. The additional metal wires were added at the of installation; the reason to preventlavoid customers from standing and fall to the pavement below.
4.2 In response to concern Ire progressing a project in conjunction with to permanently enclose
4.3 Planning permission was previously granted in 2015 by City of London for a full enclosure to including fully enclosed sides. The planning consent lapsed in the meantime_
4.4 have now received a detailed proposal from Scheldebouw which allows for a modular steel framed enclosure to The additional structure will have a roof with an electric louvre system to allow for ventilation but will fully enclose
4.5 It has been by at enclosing s the best solution and Scheldbeouw were formally instructed on 13 May 2025 to produce the detailed designs_ being day being not being not being being point against fully agreed

4.6 As the design is still in the developmental stage and whilst the structural and wind calculations have taken place, the design will have to go through planning application process and approval would also be needed from Mr Russell Pengelly; the Design Out Crime Officer/ Architectural Liaison Officer (ASB/Crime Prevention Advisor) prior to the planning application submitted. Jare in contact with Mr Pengelly.
4.7 The exact timescales for this project are unknown as it is in the design and planning phase. Expects this would take at last 12 months_ This will remove the need for horizontal metal wires and deals with concern (ii) as regards The structure will no longer be surmountable.
4.8 In the meantime, we understand that] will the closed to the public until permanent alterations have taken place encloscd. PROPOSED STRUCTURAL CHANGES TO
5.1 As outlined above, following the death of Mr Hadgu, it was concluded that the metal wires would be effective to increase the height of the barrier, thereby making it significantly more difficult to climb over the barrier: The additional height by way of metal wires was added by March 2023_
5.2 Whilst was not relevant to the unfortunate incident on 27 March 2025, (understands the importance of making further structural changes in addition to those made in March 2023,to further prevent persons from being able to surmount the barriers_ 53 In response to concern are progressing designs to increase the height of barrier and change nature of the barrier; by removing the horizontal metal wires_ have now received a detailed proposal from Scheldebouw which increases the height of the barrier from 2.4m (1.39m glass, with the metal wires extending it to 2.4m) to 2.8m whilst also removing the handrails and footrails In this design the existing glass and base brackets will remain in situ and new 2.8m posts will be installed to support new glazing that will be added to increase the height of the barrier to 2.8m The barrier will therefore be made up completely of glazing up to a height of 2.8m_
5.4 lanticipate that the structural alterations to will be completed by Autum 2025_
5.5 Scheldebouw have carried out preliminary design works and modelling for this location, but it will further development throughout the proposed S-week pre-construction phase to finalise the drawings and specifications
5.6 This will alleviate the need for horizontal metal wires and deals with concern as regards
5.7 have informed us that will also remain closed to the public until permanent alternations have taken place to the barrier: being keep and require

5.8 Again, such recommendations for alternations to the design of the barriers need to be signed off by Mr Russell Pengelly, the Design Out Crime Officer/Architectural Liaison Officer (ASB/Crime Prevention Advisor). As outlined abovel are in contact with Mr Pengelly and he has been invited to the kick-off call with Scheldebouw which is scheduled to take place in 2025
5.9 As per the recommendations in the Public Health report, post installation of the approved design changes, a plan will be set up to allow officers to revisit and follow up with ensure safety is upheld: OTHER CONCERNS SECURITY AND CCTV)
6.1 It has been identified that theb as well as the present risk as it mitigates the height of the barriers when lowards the barriers, presenting a platform to climb onto the barriers.
6.2 It has been recommended in the Public Health report that remove these land kept away from the edges a It has been suggested that obtain alternative for the are focusing on in place and away from the edges to prevent people from at all, providing greater security. understands that will seek alternative designs to remove the risk the current layout presents and to deal with concern (ii) raised by the coroner; in conjunction with heightening the barrier on and permanently enclosing
6.3 As regards concern (iv) the are responsible for and provide security personnel for the
6.4 As regards concern whilst there is CCTV covering the risk assessment established that neither CCTV covers The Public Health report comments that Whilst this is not a breach of the licensing condition attached t0 the premises licence, the CCTV should cover all operational areas: It has been agreed that the Licensing Team will work with_ to enhance coverage once the design and build is more advanced and potentially refresh the condition attached to the licence by way of minor variation. Such designs will take account of the umbrella placements to ensure this does not block CCTV coverage do not propose increasing their CCTV coverage in this areas as review and actioning anything seen on the CCTV in real time would present practical issues i.e,, Isecurity who arc based on the floor would not have direct contact with and would be too far away to act in an emergency situation_ RELEASE OF THE RESPONSE PUBLICATION OF RESPONSES
7.1 Our instructed solicitors CMS Cameron McKenna Nabarro Olswang LLP (CMS"' contacted the coroner on 4 April 2025 as regards the publication of the Notice and any responses. The concern raised at the time was to invite the coroner not to publish the Notice in the immediate future as s0 may encourage copycat attempts. May designs They ground doing

7.2 We are grateful for the coroner's agreement that the Notice will not be published in the meantime. Upon publication of the Notice and responses, for the same reasons; we would invite the coroner to extensively redact the information within to avoid a member ofthe public from reviewing them and establishing how to circumvent any control measures in place at the CONCLUSION
8.1 We thank you for your time taken to prepare the Notice and for permitting US to review the information provided.
8.2 Wwvill continue to engage with the necessary parties to ensure that changes are made in an expedited manner to achieve safe and compliant roof terrace areas

Dear Ms Hewitt, HM Senior Coroner for the City of London Regulation 28 Report, dated 3 April 2025 - Re: Alexander CARDOZA (deceased) We write in response to your Regulation 28 Report, dated 3 April 2025. We would like to take the opportunity to express our deepest condolences to the family and friends of Mr Cardoza. takes the safety and security of its customers very seriously. Working in conjunction with the landlord (the "Landlord"), we regularly conduct safety risk assessments and audits, with the help of external expert advisers, and upgrade where appropriate the premises and operational processes. Following careful consideration of the matters raised in the Regulation 28 Report, we respectfully provide the following response. The

leases the from the Landlord and has done since March 2011. has two

The Landlord is responsible for the structure and has full day-to-day control over the operation of (including decorating and furnishing). We work collaboratively together in respect of safety and security. Previous Incident and Subsequent Action Undertaken The Regulation 28 Report references the previous (and only other) sudden non-suspicious death at in November 2022. This incident occurred at , which at the time had
1.39m high glass balustrades, compliant with Building Regulation requirements (being 1.10m). Mr Cardoza passed away after , which was the first and only incident . By early 2023, the following action had already been taken in respect of :
1. Fencing was added glazing balustrade increasing its height to 2.4m. The already had the additional fencing so had balustrades of that 2.4m height when the incident occurred. This is significantly higher than the minimum height stipulated for balustrades in the Approved Document Part K of the Building Regulations.
2. All seating backing onto the balustrades were removed to prevent individuals approaching the balustrade directly. has never had any seating backing directly onto the balustrades and did not at the time of this recent incident.

3. Processes were also updated so that in addition to having a member of our staff always present whenever it is accessible, also has a dedicated security guard present from 3pm onwards to monitor the perimeter area. These changes were following a Risk Assessment report we prepared with the Landlord (who we understand had appointed a health and safety consultant to provide advice in this regard), following an analysis , and finalised on 16 February 2023. Current Position At present, remain closed. is also padlocked shut. will not be opened until the balustrades have been increased to a height of at least 3m. We are working with the Landlord to progress this but do not have an exact timeframe at this stage. Following consultations with external advisers (Citation (Health & Safety Consultants), the City of London police and City and Hackney Public Health team) once are reopened, the following operational changes will be in effect:
1. When reopen, all furniture will either be fixed to the floor and will not be able to be moved or for certain items such as chairs and other seating which require some movement to be usable, these will be secured to the floor using chains. No furniture will be close to the balustrades, and it will not be possible to move any freestanding furniture to the balustrades.
2. Training:
a. training was provided to Heads of Department staff on 14 December 2022 and in March 2023 and then refresher courses were provided on 14 June 2024 and 27 May 2025.
b. Prior to reopening of , all staff working for will receive training on (regardless of their role) and this training will be refreshed on a biannual basis. We have already asked (as recommended by the City of London Police) to train existing staff members so that they are better prepared to spot red flags. All new staff members will be required to complete internal training on our E-learning platform before they can begin working at .
c. All outsourced security staff will also be required to have completed

and intervention training prior to working for us.
3. Staff and security member present on :
a. At the time of this incident, there were three staff members working . There is always at least one staff member working when open.
b. As noted above, always has a security guard present monitoring the balustrades when open from 3pm onwards and an additional security guard controlling access to itself. A security guard monitors the from 3pm daily during peak business times as agreed with the Landlord, so was therefore not there at the time of the incident.

c. We are awaiting a final risk assessment report from Citation which we expect to receive shortly. In conjunction with all the other steps undertaken, this will consider whether further staff or security measures need to be put in place and we will adjust protocols further to their recommendations in due course as necessary.
4. CCTV covers both and has done since

were opened. At the time of the incident, the angle of the cameras on resulted in a blind spot. We have since adjusted the camera angles to improve coverage, and the CCTV system now covers approximately 95% of . The CCTV at the premises is (and has always been) compliant with the terms of our licensing requirements and we cannot in fact add any more cameras as we have reached the limit of the system. We do not address any changes to the physical structural barriers in any detail here as the Landlord is taking steps to upgrade these. The plan is to upgrade the balustrades to a height of at least 3m and make them solely of strengthened glass but this is subject to planning constraints and structural implications regarding anticipated wind loads. will remain closed while this design process continues, and the Landlord will be able to expand further on these plans. We will continue to support the Landlord, but we cannot comment further on the decision-making process behind the changes that were made and continue to be made. In the longer term, we, in conjunction with the Landlord, have planning permission to permanently enclose . We are in the process of agreeing the terms and process for doing this with the Landlord. Conclusion takes safety and security extremely seriously. It has already implemented a number of process changes which will immediately come into effect once reopen and is working with the Landlord in respect of the safety of . Along with the Landlord, we will continue to monitor the effectiveness of the proposed changes and will make further operational upgrades should it be necessary to do so, working with external experts as appropriate. We trust the additional information set out above helps address any concerns that the Coroner has regarding the operational safety of .