Sandra Senior
PFD Report
All Responded
Ref: 2024-0124
All 1 response received
· Deadline: 29 Apr 2024
Coroner's Concerns (AI summary)
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
View full coroner's concerns
(1) The London Borough of Camden Council is the Freeholder of Tavistock Chambers. I learned in evidence from local witnesses and officers from the Metropolitan Police Service that Miss Senior’s death, as a result of using to complete suicide, was the second of its type within approximately 18-months.
The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door , which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service.
There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access
.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign , it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.”
It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building were not working effectively at that time.
The concern is that it appears that the safety systems in place to stop unauthorised access in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace.
The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door , which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service.
There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access
.” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign , it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.”
It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building were not working effectively at that time.
The concern is that it appears that the safety systems in place to stop unauthorised access in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace.
Responses
Action Taken
The council removed the latch and hook from the communal door, installed an extra "Fire Brigade" lock on the rooftop exit, and relies on daily checks by the caretaking service to secure doors and report faults. (AI summary)
The council removed the latch and hook from the communal door, installed an extra "Fire Brigade" lock on the rooftop exit, and relies on daily checks by the caretaking service to secure doors and report faults. (AI summary)
View full response
Dear Mr. Potter, Regulation 28 – Prevention of Future Deaths Report Sandra Elizabeth SENIOR (died 24 September 2023)
Thank you for your report dated 4th March 2024. We were saddened to read your report and the circumstances of the death of Sandra Senior. This letter sets out the enquiries we have made in relation to your recommendations, and the steps we have taken to address the risks identified.
Communal front entrance door
On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.
Roof top exit
For the roof top exit we have installed an extra “Fire Brigade” lock that requires a different key. It is unfortunately the case that suited keys that are used by the London Fire Brigade, and our maintenance teams, can be procured by members of the public who wish to access restricted areas (for example for recreational use or pirate radio station broadcasts). This can lead to roof top exits, or doors to machinery and intake cupboards, being left open at times. Hopefully the addition of this further lock will deter casual access.
Caretaking service
The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service.
I hope this letter sets out clearly our approach to managing the risk in relation to roof top exits, and the specific issues identified at this block. Again, we were saddened to hear about the passing of Ms. Senior, and we welcome the report that you provided following the inquest.
Thank you for your report dated 4th March 2024. We were saddened to read your report and the circumstances of the death of Sandra Senior. This letter sets out the enquiries we have made in relation to your recommendations, and the steps we have taken to address the risks identified.
Communal front entrance door
On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur.
Roof top exit
For the roof top exit we have installed an extra “Fire Brigade” lock that requires a different key. It is unfortunately the case that suited keys that are used by the London Fire Brigade, and our maintenance teams, can be procured by members of the public who wish to access restricted areas (for example for recreational use or pirate radio station broadcasts). This can lead to roof top exits, or doors to machinery and intake cupboards, being left open at times. Hopefully the addition of this further lock will deter casual access.
Caretaking service
The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service.
I hope this letter sets out clearly our approach to managing the risk in relation to roof top exits, and the specific issues identified at this block. Again, we were saddened to hear about the passing of Ms. Senior, and we welcome the report that you provided following the inquest.
Sent To
- Camden Council
Response Status
Linked responses
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56-Day Deadline
29 Apr 2024
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 6 October 2023, an investigation was commenced into the death of Sandra Elizabeth SENIOR, then aged 58 years. The investigation concluded at the end of an inquest, heard by me, on 28 February 2024.
The conclusion of the inquest was suicide, the medical cause of death being:
1a multiple traumatic injuries
The conclusion of the inquest was suicide, the medical cause of death being:
1a multiple traumatic injuries
Circumstances of the Death
On 24 September 2023, Sandra Senior travelled to central London. While there she gained access to Tavistock Chambers, Bloomsbury, WC1A; a building comprising of commercial units on the ground floor, with four floors of residential accommodation above.
completed suicide
completed suicide
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.