Dear Madam, Re. Regulation 28 Prevention of Future Deaths Report issued following the Inquest into the death of Mr Daniel Coleman

I am writing in response to the Prevention of Future Death (“PFD”) Report dated 25 August 2020 which was issued following the Inquest into the death of Mr Coleman who sadly passed away on 14 February 2020 following an accidental fire caused by his own production of crystal meth. Background Mr Coleman was an agency employed Construction Manager whose role at the time of the incident was to oversee the pre-demolition works at Aspen House (“the Site”) before the Site was handed over to the demolition contractors. Mr Coleman was an experienced and qualified individual, with 18 years’ experience of managing construction-related activities including demolition, new build and civil engineering projects. The toxicology report identified that illegal substances had been taken by Mr Coleman prior to his death. Prior to this tragic incident, no concerns had been raised with the London Borough of Camden (“the Council”) regarding Mr Coleman’s work performance or conduct that led to any suspicion that he was taking an illegal substance. The PFD Report In the PFD report, there are nine Matters of Concern (“the Matters”) outlined by Her Majesty’s Coroner, some of which relate to the Council and some of which fall within the undertaking of First Response Facilities Management Ltd (“First Response”), the specialist security contractor appointed by the Council to secure the Site, to whom a copy of your PFD report was also issued. Many of the Matters raised address responsibilities which cross over between the Council and First Response and Her Majesty’s Coroner may therefore receive duplicate responses. This response is prepared on behalf of the Council, in relation to the six Matters that it feels able to respond to. There is some overlap between the six Matters, but in summary they can be said to relate to: (a) Security arrangements (Matters 1 and 2) – these concerns relate to the fact that neither the security officers employed by First Response nor employees of Camden Council were aware that Mr Coleman was living on its sites. You may recall that the Council was not aware that Mr Coleman was living on the Aspen House site prior to this Inquest but it was determined by the Court on the balance of probabilities after hearing all of the evidence that he was.

26th October 2020

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(b) Site signing in/out records (Matter 6) - this concern relates to the fact that the signing in/out record produced by the police to the Court was incomplete.

(c) Drug and Alcohol policy (Matters 7, 8 and 9) - these concerns relate to the fact that Mr Coleman had not been identified as being a person under the influence of drugs, and that neither he nor others had (at the time) been tested under the Council’s drug and alcohol policy. Matters 3, 4 and 5 relate in the main to the Coroner’s interpretation of the evidence given at the Inquest by First Response employees. The Council heard the evidence given to the Inquest by the First Response security guards under oath, and it makes no comment or observations about that evidence. The Council considers that Matters 3, 4 and 5 are concerns that First Response would be best placed to respond to however the Coroner’s general concern regarding the security arrangements in place are covered below. Measures already in place prior to Mr Coleman’s death The Inquest process explored some (but not all) of the procedures that the Council already had in place to manage the security arrangements on site at Aspen House. Because the property was vacant, the Council had made arrangements for the Site to be secured, and, as above, the Council had engaged a security company, First Response, to provide 24/7 security to Aspen House. First Response was engaged and on site from September 2019 onwards so as to prevent any unauthorised use or trespassers on Site. By way of reminder, the security arrangements that First Response had put in place were as follows: (a) Hoarding/fencing to secure the perimeter of the development, with metal security hoarding to the ground floor of Aspen House; (b) A metal security door to the block was locked with a key. Keys were held only by on-site security and Mr Coleman; (c) An intruder alarm had been fitted covering access/egress points. There were intruder alarm sensors behind the front door (as you entered the block) and on the first floor landing. The security alarm panel, if activated, would sound in the security office located in Flat 5; (d) All persons on entry and exit to the development were required to sign a ‘sign in’ register; (e) First Response had one trained security officer on site during the day and two trained security officers present during the night. There was security staff on site at all times, 24 hours a day, 7 days a week, to ensure that there was no sign of disturbance or trespass; and, (f) The security officers conducted perimeter checks of the building on a regular basis to satisfy themselves that there had been no unauthorised access to the building. Prior to the incident involving Mr Coleman, the Council had never been made aware of any intruders or trespassers on the Site and it had never received any concerns about any workers, including Mr Coleman, living on any of its sites (including Aspen House and Bacton Low Rise). The Council’s response Following the Incident, and prior to the Inquest, the Council conducted a full review of its properties earmarked for future development projects i.e. either properties that were empty or had live in guardians in place for security purposes. Inspections were carried out of those properties to check for potential unauthorised access/use and nothing was found, indicating

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that the security arrangements in place were suitable. Despite this, the Council has subsequently further reviewed and made various enhancements to its procedures as follows: (a) Security arrangements As outlined above, the Council already had in place comprehensive systems for the security arrangements at Aspen House. Nevertheless, the Council has over the last few months considered its relationship with security providers across its operations and has developed a ‘Site Security Scope of Service’ specification (“the Specification”) for use across all of its contracts that require contracted security services. The Specification sets out the Council’s expectation of the standards employed by the security contractors that it engages. Third party security companies such as First Response, will be required to adhere to the requirements outlined in the Specification at all times. The Specification is currently in an advanced draft stage and is imminently due to go through the Council’s internal approval and implementation process. It is expected that training sessions will be delivered for Development teams on the new Specification by the end of November 2020, with all existing contracts on its Development projects to be moved across to work in line with the Specification by the end of the year. The Specification, once approved, will:  Include detailed information for security contractors on the processes to be followed, and the documents to be completed as part of the security officers’ checks/patrols of the property. The Council had considered that its rule that nobody was allowed to sleep on site was well known but for the avoidance of doubt, the Specification will include a clause to the effect that at no time will the Council allow persons to use empty properties for accommodation (unless they are guardian properties) and the contractor is explicitly required to maintain security to that extent.

 Require improved reporting to the Council by the security contractors by way of a self-audit process. In brief, security contractors going forward will be required to issue all completed documentation (for example site log books, inspection reports and incident reports) electronically to the Council on a weekly basis so that compliance with the Specification can be monitored.

 Contain Key Performance Indicators against which the security contractor’s performance will be monitored. Any security contractor who fails to meet the Council’s standard will be managed accordingly. In addition to the Specification, and the compliance requirements outlined within it, the Council will continue to undertake monthly meetings with its security providers as a secondary level of monitoring. The Council continues to explore ways that it might be able to further discourage behaviour such as that heard in evidence as displayed by Mr Coleman. For example, the Council is working with the relevant departments to see whether it can make void properties more uninhabitable/unattractive to trespassers, for example by destroying the toilets/washing facilities once the property is empty of residents and guardians. Any decision would be subject to risk assessment and this would need to be approached on a site by site basis because some facilities such as toilets, electricity and running water would be required to facilitate the security arrangements (alarms/CCTV) and for welfare purposes.

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(b) Site signing in/out records First Response was required to maintain site records and to require all visitors to the Site to sign in and out. The police seized the signing in book after the fire when they arrived on site and it was later disclosed to the Council after the Inquest had commenced. The copy of the book that was disclosed appeared incomplete but it was not clear why that was the case and the officer who seized the book was not called to give evidence at the inquest. As part of the audit of the new Specification process outlined above, the Council will, going forward, require all security contractors to submit, on a weekly basis, a report of site activity and sign in/out logs to be sent to the Council’s named project team. This will identify if any security contractor is not fulfilling its responsibility to ensure that all visitors sign in and out of sites, and it will identify any unauthorised use of the site outside of working hours. (c) Drug and Alcohol policy The Council notes that one of the Coroner’s concerns is that none of Mr Coleman’s managers or colleagues noticed that he was intoxicated or under the influence of drugs. It is of note that the same observation was given by Mr Coleman’s friend, who also gave evidence to the Inquest. The Council has no reason to believe that those witnesses would not have told the truth under oath about their observations of Mr Coleman’s behaviour. This would align with the fact that the Council had at no point during Mr Coleman’s employment been made aware of any concerns regarding Mr Coleman’s work performance or conduct that led to any suspicion that he was taking an illegal substance. Her Majesty’s Coroner was provided with a copy of the Council’s Substance Misuse Policy (“the Policy”). The Policy was in its infancy at the time of Mr Coleman’s incident and at the time of the Inquest it was undergoing consultation and review. I have now been provided with further detail regarding this Policy from the relevant departments within the Council, and its intended use going forward. Hopefully the Court will appreciate that a policy of this nature (which enables testing of employees and which can result in disciplinary action being taken) is not a straightforward policy to roll out and it inevitably takes some time to consult with the relevant persons and to get the required ‘buy in’. In the weeks following this Inquest, the Council has sought to revisit the Policy and has made some changes to it to make sure that it is legally compliant and in line with current best practice. Hampton Knight, the Council’s specialist drug and alcohol consultants, are advising on this process. Trade Unions are currently being consulted on the Policy and it is hoped that formal consultation will be complete before the end of the year, with the testing regime to be rolled out in the new year. The final content of the Policy and the timeline for rolling it out are very much dependent on (a) the ongoing discussions with Hampton Knight and the Trade Unions; and (b) the continued impact of the coronavirus pandemic which as the Court may anticipate has taken up an extraordinary amount of time and resource from the Council’s health and safety department since February 2020. Despite this, progress has been made in the review and rollout of the updated Policy as outlined in this section. Her Majesty’s Coroner may recall from the evidence at the Inquest that some employment roles are identified as safety critical for drug testing under the Policy, such as those who

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operate heavy machinery or who drive Council vehicles. Management roles, including Construction Managers, would not have at the time fallen within the definition of safety critical within the Policy and that will continue to be the case going forward, in line with industry standard. Conclusion The safety of the Council’s employees and all those affected by its operations is of the utmost importance to the Council. All those who knew Mr Coleman were saddened and shocked upon learning of the events that led to his death. We trust that the above is of assistance.