REDACTED

Regulation 28:  Prevention of Future Deaths report 

THIS REPORT IS BEING SENT TO: 

1. 

Commissioner 
London Fire Brigade 
169 Union Street 
London SE1 0LL 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On  8  August  2023,  I  commenced  an  investigation  into  the  death  of 
. The investigation concluded at the end 

of the inquest on 15 January 2024.   

I  made  a  determination  at  inquest  of  death  by  suicide.   
jumped from the roof of his block of flats at 5.33pm on 26 July 2023.   

4 

CIRCUMSTANCES OF THE DEATH 

Before he jumped off the roof, 
Service (MPS), who in turn called the London Fire Brigade (LFB).   

 called the Metropolitan Police 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 When  police  officers  tried  to  negotiate  with  him, 
  appeared 
receptive to the idea of coming down off the roof safely.  Police officers 
were reluctant to suggest that he return the way he had come, as by now 
it  was  raining  and  they  were  concerned  that  he  would  slip,  and  so  he 
waited on the roof for firefighters to escort him. 

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

1. 

  rang  police  at  4.33pm,  exactly  one  hour  before  he 
actually  jumped  off  the  roof.    Police  attended  immediately  and 
sought 
they 
reported  to  me  at  inquest  that  there  was  some  delay  in  the 
attendance of LFB. 

firefighter  assistance 

immediately. 

  However, 

2.  Upon attendance, firefighters recognised that their ladders would 
not reach the roof of the flats and so called for an extended height 
ladder  appliance.    This  had  to  travel  from  further  afield  and 

 became more agitated during the wait.  It had not arrived 

at 5.33pm when he jumped.   

The  police  were  especially  concerned  that  the  extended  height 
ladder appliance had not been requested from the outset, given 
that the call was in respect of a person on the roof of a block of 
flats. 

I  did  not  take  evidence  from  any  firefighters  at  inquest,  and  so  I 
appreciate that there may be elements of which I am unaware. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 18 March 2024.  I, the coroner, may extend the 
period. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the following. 

• 
• 
•  HHJ Thomas Teague QC, the Chief Coroner of England & Wales 

, sister of 

, wife of 

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

18.01.24                                              ME Hassell 

3

London Fire Brigade Headquarters 
169 Union Street  London  SE1 0LL 
T 020 8555 1200  
london-fire.gov.uk 

The London Fire Commissioner is the 
fire and rescue authority for London 

Date  11th March 2024 

Coroner ME Hassell  
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London  
N1C 4PP 

Dear Coroner 

Prevention of Future Death Report: 

 (died 26.07.23) 

I write in response to your Regulation 28 report in the above case, which was received by LFB on 22nd 
January 2024.    

To adequately respond to the concerns raised in your report, the London Fire Brigade [‘LFB’] has made 
extensive internal enquiries of officers involved in the incident that resulted in the death of 

At this juncture, the information obtained from LFB personnel involved in the incident, appears 
incongruous with the actions noted in your report. 

As HM Coroner will know, the LFB was not recognised as an Interested Person; indeed the LFB was 
unaware of the inquest taking place.  HM Coroner noted in the Regulation 28 report: “I did not take 
evidence from any firefighters at inquest, and so I appreciate that there may be elements of which I am 
unaware.” 

In the circumstances, and in order to enable a proper Regulation 28 response, the LFB requests the 
following: 

(i)  An extension of 28 days (in the first instance) to respond to the Regulation 28 report; 
(ii)  A copy of the Record of Inquest; 
(iii) A copy of the written disclosure made to the Interested Persons; 
(iv) A copy of the audio recording of the inquest. 

I look forward to hearing from you. 

Yours sincerely 

General Litigation Unit Manager