Daniel Coleman

London Borough of Camden Council 
5 Pancras Square 
N1C 4AG 
Tel: 

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. 

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26th October 2020 
 
 
 
 
 
 
 
 
 
 (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. 

Yours faithfully, 

– Head of Safer Homes 

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