Arezou Tirgari

City of London Coroner’s  Court 

Before HM Senior Coroner Ms Alison Hewitt 

Response to the Report to Prevent Future Deaths on behalf of LS One New Change 
Limited 

STATEMENT OF 

I, 

1. 

2. 

3. 

, of Land Securities Properties Limited, will say as follows: 

My name is 
, and I am Head of Workplace Operations and a Senior Leader 
within Landsec Securities Properties Limited. I am duly authorised to make this statement 
on behalf of LS One New Change Limited. One  New Change  (‘ONC’) is  owned  by LS One 
New Change Limited (‘Landsec’). The information contained within this statement has been 
collated through consultation with stakeholders and it is true to the best of my knowledge 
and belief. 

I  make  this  statement  in  response  to  the  Report  to  Prevent  Future  Deaths  dated  3  July 
2023 made by HM Senior Coroner Ms Alison Hewitt. At the outset, I would like to offer my 
personal,  sincere  condolences to  Ms Tirgari’s  family  and  friends at  this extremely  difficult 
time. The safety of our visitors is our utmost priority and Landsec is committed to ensuring 
every visitor has a safe and enjoyable experience while visiting our sites. 

Landsec is grateful for the opportunity to comment and contribute to the efforts that seek 
to prevent future tragedy.  The purpose of this statement is to provide information on the 
arrangements in  place at  the  time  of  Ms Tirgari’s  death  and  changes made  subsequently. 
We  wish  to  assure  the  Learned  Coroner that  sufficient  action  has been  taken to  prevent 
persons being able to climb the perimeter wall and that there is no risk to any persons who 
visit ONC. 

Background 

4. 

5. 

I have been employed by Landsec Securities Properties Limited for over 10 years and have 
approximately 22 years property management experience. I have extensive knowledge of 
Landsec’s  assets  and  hold  overall  responsibility  for  the  operational  management  of  a 
commercial and mixed use property portfolio, in excess of 5 million square feet, including 
ONC. 

As  Head  of  Workplace  Operations,  I  am  responsible  for  the  operational  delivery  of  all 
property related services including security, engineering, cleaning and front of house. I am 
also responsible for the management of all directly employed operational management staff 
(of which there are 53 and our out-sourced service partner teams, of which there are 527). 

One New Change 

On  25  December  2006,  LS  One  New  Change  Limited  took  a  155  year  leasehold  interest 
from the City of London over the land where ONC is now built. Landsec was responsible for 
the development, construction and practical completion of ONC and remains the property 
manager of the Site. 

ONC has approximately 310,000 square feet of offices over levels 2 to 6 and circa 210,000 
square  feet  of  retail  over  ground  floor,  lower  ground  floor  and  first  floor.  There  is  a 
restaurant and bar on level 6 currently leased to Madison Restaurant Limited. 

The public roof terrace is private land, located on level 6, a photograph of which is exhibited 
at  Appendix  1.  Since  the  terrace  opened  in  November  2010,  Landsec  estimate  that 
approximately 25 million members of the public have visited. 

6. 

7. 

8. 

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 9. 

A Section 106 Agreement is in place between the City of London and Landsec.  A Section 
106  Agreement  is  a  legal  agreement  between  a  planning  authority  and  developer,  or 
undertakings offered unilaterally by a developer, that ensure certain extra works relating 
to the development are undertaken. Under the terms of the Section 106 Agreement dated 
7 June 2006 between the City of London and Landsec, Landsec are  ‘……to keep the Roof 
Terrace open to the public for access on foot as a viewing area for recreation and viewing 
purposes (to which access may be gained by members of the public free of charge) at all 
times from the  Roof  Terrace Area Opening  Date….’ As per the  plan, exhibited at Appendix 
2, Annexure 7 to the Section 106 Agreement, the terrace is to remain open to members of 
the public from 6 am through to midnight every day of the week. 

Circumstances  of Ms Tirgari’s  death 

10. 

11. 

I have had the opportunity to review the CCTV footage which captured the tragic events on 
1 June 2023. It is my understanding the CCTV footage has been provided to the Learned 
Coroner. 

Following  a  detailed  review  of  the  CCTV,  the  facts as  we  currently  understand  them  are 
that: 

• 

• 

• 

Ms Tirgari arrived at ONC at 14:12. She looked up from the ground floor on New 
Change  Passage  towards  the  public  roof terrace 

 and entered it at 14:13, reaching level 6 at 14:14. 

Once  on  the  public  terrace,  Ms  Tirgari  walked 
,  located 
approximately  4.7  metres  away  from  the  perimeter  wall.  It  appears  from  the 
CCTV  that  Ms  Tirgari  engaged  in  a  conversation  with  another  visitor  for 
approximately 10 minutes. 

At 14:32, Ms Tirgari had something to drink and walked under the Tensabarriers 
(weighted posts incorporating retractable safety tape capable of being linked to 
other Tensabarrier stands, thereby acting as a continuous fence) and over to the 
perimeter wall. 

 Once over the wall, Ms Tirgari leaves the view of the 

camera. 

12. 

At this very early stage in the proceedings, and in the absence of any findings of facts from 
the Coronial investigation, we have acted upon the data we hold. We will ensure that we 
share any additional evidence that comes to light during the course of our investigation. 

Safety measures in place at ONC on 1 June 2023 

13. 

The  Learned  Coroner  is  directed  to  Appendix  3  which  encloses  a  plan  of  the  public  roof 
terrace,  the  location  of  the  security  officers,  photographs  of  the  exclusion  zone  and 
photographs of the warning drop signs, all of which were in place at the time of Ms Tirgari’s 
death. 

14. 

At  the time of Ms Tirgari’s death, Landsec had the following measures in place: 

• 

• 

• 

One  walking  patrol  security  officer  on  the  public  roof  terrace  during  opening 
hours, (6am to midnight), as annotated by the red dot on the attached plan at 
Appendix 3. 

Two metre continuous exclusion zone along the southern boundary of the public 
roof  terrace  (from  west  to  east)  and  parallel  with  the  perimeter  wall,  as 
annotated by the green line on the attached plan at Appendix 3. This zone was 
delineated by Tensabarriers. 

Security officers changed over on the day of incident at the location of the green 
dot. 

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 • 

‘Warning  Sudden  Drop’  signs  were,  and  remain  located,  at  3.7  metre  to  7.4 
metre  intervals  along  the  vertical  edge  of  the  perimeter  wall.  Please  see  the 
image at Appendix 3, which is an example. 

The Design and Height of the Perimeter Wall 

15. 

16. 

During the design and construction of ONC, Landsec ensured that it complied wholly with 
the Building Regulations which were in place at the time. The Building Regulation Approved 
Document Part K: ‘Protection from Falling, Collison and Impact’ and section K2: ‘Protection 
from falling’ requires public accessible pedestrian  guarding to  be  1100mm high. 

Landsec’s  architects  have  reviewed  the  information  it  holds  relating  to  the  height  of  the 
perimeter wall. The architects have confirmed following a review of the archived information 
that: 

• 

• 

• 

• 

The perimeter raking guarding by the section of green roof is approximately a 
minimum 1100mm AFFL (Above Finished Floor Level) but varies according to 
changes in the terrace level for drainage; 

The  perimeter  raking  guarding  to  the  lower  terrace  is  a  minimum  of  1100-
1155mm AFFL but varies according to changes in the terrace level for drainage; 

The perimeter wall is a minimum of 1100mm by the scenic lift and a minimum 
of 1830mm at the base of the stairs to the lower section of Madison’s restaurant 
terrace; 

The perimeter wall is a minimum of 1100mm by the scenic lift then generally 
increases in height with variations in level as the public terrace steps down. The 
variations are due to the general geometry of the perimeter wall, which in some 
places has a gradient to the top surface, with other changes due to the geometry 
of the stepped terracing levels, plus further minor variations in floor finish levels 
to allow for drainage falls. 

17. 

At  the  time  of  constructing  ONC  between  2007-2010,  I  have  been  informed  that  Public 
Health England’s ‘Preventing Suicides in Public Places, a practical resource’ (2015)  and The 
City of London’s SPG document  ‘Preventing Suicides in  High  Rise Buildings and Structures, 
Planning  Advice Note’ (April  2022) was yet  to  be  published. The two incidents identified to 
the Learned Coroner in 2023 were the first incidents of this kind at ONC. 

Current Safety Measures 

18. 

Immediately  after  the  incident  on  1  June  2023,  the  following  additional  preventative 
measures were implemented in addition to those listed at paragraph 14 above: 

• 

• 

• 

• 

The public roof terrace was immediately closed until further notice. 

Two  lines  of  Tensabarriers  were  installed  across  the  width  of  the  terrace 
entrance,  as  annotated  by  the  two  green  lines  on  the  drawing  enclosed  at 
Appendix 4. 

Two Landsec security officers were positioned between the Tensabarriers from 
12:00/noon to 00:00/midnight each day. 

The two scenic lifts were re-programmed: 

• 

• 

The right hand side lift was re-programmed to grant access to the 
lower ground, ground and first floor. There was no access to level 
6. 

The  left  hand  side  lift  was  reprogrammed  to  coincide  with 
Madison’s opening hours (12:00/noon to 00:00/midnight). Access 

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 was  permitted  to  level  6  only  from  the  ground  floor  where 
Madison’s staff and  ONC security officers were  located. 

• 

• 

• 

One Landsec security officer was positioned outside the scenic lifts on the ground 
floor from 07:00 to 00:00/midnight to engage with public and advise why the 
terrace is closed. 

During  the  week  commencing  5th  June  2023,  Madison  moved  their  planters 
across to the top of the first step to the public roof terrace, thereby providing a 
further  physical  barrier  to  prevent  the  public  accessing  the  roof  terrace  (as 
annotated by the blue line on the drawing attached at Appendix 4.) 

Two additional security officers were located at Madison. 

19. 

In addition, Landsec has appointed a team to design and install a hoarding approximately 
2.5  metres  in  height  across  the  terrace  in  the  current  location  of  the  Tensabarriers. 
Following advice from Landsec’s structural engineers and its fabrication team, this hoarding 
is due to be installed in early September 2023. It is to remain in situ until the permanent 
works (discussed below) are completed which is estimated between April and June 2024. 

Future Works 

20. 

21. 

Since  Ms  Tirgari’s  death  Landsec  has  held  planning  meetings  with  the  City  of  London’s 
planning  team,  including  the  Planning  and  Development  Director,  the  Senior  Planning 
Officer and the Senior Public Health Practitioner. A pre-planning application meeting with 
the City of London is being sought for September 2023 and, subject to the outcome of that 
meeting, a full planning application will be submitted in October 2023, with works estimated 
to be completed between April and June 2024. 

At the time of writing, I can confirm that the proposed permanent works are currently at 
the design stage and no final decisions have yet been made. However, capital has been set 
aside  to  ensure  sufficient  funding  of the  future  works.  Landsec  are  currently  exploring  a 
number  of  options  such  as  the  installation  of  a  frameless  and  transparent  glazed, 
cantilevered screen (approximately 2000mm high) which will span the entire length of the 
public  roof  terrace.  The  screen  will  be  set  back  from  the  existing  perimeter  wall  by  a 
minimum of 600mm to enable cleaning on both sides of the glazing. 

22. 

To assist in the design, Landsec has appointed the following project team: 

• 

• 

• 

• 

• 

: Project manager and contract administrator. 

 will act in 
the  capacity  of  contract  procurement,  management  and  administration  of  the 
construction contract. 

: Architect. 

 will design the proposed works and has worked 
with Landsec for over 10 years. It has been engaged on projects at ONC for over 
3 years. 

 Planning consultant with expertise in advising property owners in 
 will submit the planning application on Landsec’s 

the City of London. 
behalf to the City of London and will liaise with them. 

:  Provision  of  advice  regarding  St  Paul’s  heights  analysis  and 

associated CGI imagery. 

  Specialist  structural  engineer. 

  have  over  65  years’  structural 
engineering experience and will provide Landsec with structural advice regarding 
the works and their integration within the existing structure.  It will be also be 
responsible for the façade, as Arup are specialists in the design and engineering 
of facades. 

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 23. 

Landsec has undertaken an extensive consultation with a range of stakeholders to ensure 
that the measures that have been put in place, and the proposed measures which will be 
taken, are effective. 

Conclusion 

24. 

25. 

26. 

We would like to again express our deepest  condolences to  Ms Tirgari’s  family  and  thank 
the  Learned  Coroner  for  allowing  Landsec  the  opportunity  to  respond  and  contribute  to 
efforts being taken by all to prevent future tragedy. 

Landsec is committed to ensuring the health, safety and well-being of every person who 
visits and works at ONC. 

Landsec is a company that had a sensible and considered risk management system in place 
at the time of the incident. Since this incident, we are conducting a review of the safety of 
the roof terrace, learning lessons, and using resources to ensure that  ONC is a safe and 
enjoyable place to visit. 

27. 

If I, or the team, could assist you further, then please do not hesitate to contact me. 

Signed: 

Dated: 

5 

25/08/2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 City of London  Coroner’s Court 

Before HM Senior Coroner Ms Alison Hewitt 

Response to the Report to Prevent Future Deaths on behalf of LS One New Change 
Limited 

APPENDIX 1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 Photograph of the public roof terrace pre-incident 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 City of London  Coroner’s Court 

Before HM Senior Coroner Ms Alison Hewitt 

Response to the Report to Prevent Future Deaths on behalf of LS One New Change 
Limited 

APPENDIX 2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Public roof terrace: 

Section 106 Annexure 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 City of London  Coroner’s Court 

Before HM Senior Coroner Ms Alison Hewitt 

Response to the Report to Prevent Future Deaths on behalf of LS One New Change 
Limited 

APPENDIX 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Public roof terrace: 

Location of security officers and Ms Tirgari on 1 June 2023 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Image showing the two metre exclusion zone. 1 

1 

Please note, at the time of the incident the security officer was not situated in this exact position by the two metre 
exclusion zone. Please refer to the plan above for the location of the security officers at the time of the incident. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Example of several warning signs placed on the perimeter wall 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 City of London Coroner’s Court 
Before HM Senior Coroner Ms Alison Hewitt 

Response to the Report to Prevent Future Deaths on behalf of LS One New Change 
Limited 

APPENDIX 4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Current measures Post 1 June 2023 

Public roof terrace post 1 June 2023: 
Looking towards Madison:  line of planters across first step to the terrace, two lines of tensabarriers 
and two security officers in attendance between midday and midnight in addition to Madison security 
officers within their demise 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Public roof terrace post 1 June 2023: 

Looking from Madison - line of planters across first step to the terrace, two lines of tensabarriers and 
two security officers in attendance from midday to midnight in addition to Madison security officers 
within their demise.