Malika Hibu

Chief Executive 
Islington Council 
Islington Town Hall 
Upper Street 
N1 2UD 

www.Islington.gov.uk 

E: 

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

17 October 2024  

Dear Coroner ME Hassell, 

Thank you for sharing the Prevention of Future Deaths Report following the tragic death of Malika 
Mohammed Abdu Hibu on 17 February 2024.  

With regard to planning and the consultation on the National Planning Policy Framework (NPPF), we 
welcome the fact that you are drawing this matter to the attention of the Secretary of State. We note your 
concerns that many planning applications will be determined before changes to the NPPF are made. We 
understand that a review of the NPPF is underway and that the updated version of the NPPF will be 
published in 2025. 

Nonetheless, you may wish to ask that the Secretary of State writes to all Chief Planning Officers requiring 
that they consider potential hazards to children and vulnerable people when determining planning 
applications. Any such letter would be a material planning consideration. 

In terms of the Crest Buildings housing development, the Council is working proactively and positively with 
Peabody to bring forward a planning application for safety fencing around the canal side area of the Estate. 
The Council has held two senior level meetings with Peabody to discuss their planning application and to 
encourage them to submit the application in the most expedient manner possible. Once the application is 
submitted, we will deal with it promptly. We have also met with the residents of the Estate to explain the 
planning process and to encourage them to engage in that process 

Finally, the urban design lessons learned from this incident have been shared with all Development 
Management Officers at Islington Council. We have also checked that a planning application for another 
canal side residential development includes fencing and have confirmation that this is the case.  

Yours sincerely, 

Chief Executive, Islington Council

Deputy Prime Minister and Secretary of State for 
Housing, Communities & Local Government 
2 Marsham Street  
London  
SW1P 4DF  

Our reference: 

13 January 2025  

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

Dear ME Hassell, 

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO 
THE DEATH OF MALIKA HIBU 

Thank you for your letter and investigative report dated 7 August 2024 into the tragic death of Malika 
Hibu, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice 
Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.   

First, I want to express my sincere condolences to Malika’s family and friends. No parent should 

have to suffer through the loss of a child at such a young age and in these tragic circumstances.  

Matter of concern one – the role of Peabody 

Your  letter  and  report  were  also  addressed  to  the  Chief  Executive  of  Peabody  Trust,  and  their 
response has now been published on the Judiciary website.  

The Regulator of Social Housing has engaged directly with Peabody in relation to this tragic case 
and having assessed all relevant information against regulatory standards, has now concluded no 
further regulatory action will be taken. However, the Regulator will continue its regular engagement 
with Peabody and note the steps that Peabody is taking in response including working with other 
parties to address issues raised in the Prevention of Future Deaths notice. 

Matter of concern two – the role of national planning policy 

In your report, you “also heard that when the planning application for the 2015 housing development 

was considered in the first place, no consideration was given to the safety of the barrier as part of 
the development. I have been told that the government has announced a consultation on the national 
planning policy framework (NPPF). I have also been given to understand that section 12 sets out 
policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me 
that paragraph 135(f) could include a requirement that when development takes place in proximity 

  
 
 
 
  
     
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 to open water, railways and other hazards, special regard should be paid to ensuring the safety of 
children, young people and vulnerable adults. There will of course be many planning applications 
considered before any changes can be made to the NPPF.” 

The NPPF sets out the Government's planning policies for England and how these are expected to 
be applied. In addition to paragraph 135(f) referenced in the Coroner’s report, chapter 8 (promoting 
healthy  and  safe  communities)  provides  further  policy  on  achieving  healthy,  inclusive  and  safe 
places.   

On 12 December 2024, the Government published an updated NPPF in response to the ‘Proposed 
reforms  to  the  National  Planning  Policy  Framework  and  other  changes  to  the  planning  system’ 
consultation. As part of this update, and in direct response to findings set out in the Coroner’s report, 
additional policy has been added to paragraph 102 a) setting out that the safety of children and other 
vulnerable  users  in  proximity  to  open  water,  railways  and  other  potential  hazards  should  be 
considered in planning and assessing proposals for development. 

The  updated  NPPF  can  be  found  here:  https://www.gov.uk/government/publications/national-
planning-policy-framework--2. 

I want to thank you for bringing the tragic death of Malika to my attention and once again, I wish to 
express my sincere condolences to Malika’s family and friends. 

Yours sincerely, 

Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government

Mary Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Sreet 
London 
N1C 4PP 

By email and post:  

Date: 18 October 2024 

Dear Madam, 

Inquest arising from the dealth of Malika Hibu 

I  write  on  behalf  of  the  Mayor  of  London  (the  Mayor)  with  regard  to  the  Senior  Coroner’s 
Regulation 28 Report to Prevent Future Deaths (PFD) dated 7 August 2024 following the inquest 
arising from the death of Malika Hibu.  

I am the Assistant Director of Planning & Regeneration at the Greater London Authority (GLA), 
and I am responding to the PFD report on the Mayor’s behalf.  

The Senior Coroner’s PFD report 

Malika tragically died on 17 February 2024 and the inquest into her death concluded on 17 July 
2024. The Mayor was not an Interested Person in the inquest. 

Firstly, I want to take this opportunity to offer our sincere condolences to the family and friends 
of Malika.  

The PFD report is addressed to the Chief Executive of the Peabody Trust, the Chief Executive of 
Islington Borough Council, the Secretary of State for MHCLG and the Mayor. The PFD report 
raises the following matter of concern: 

‘The railing next to the canal afforded no protection against the water for a small child. In fact, 
an adult could easily fit through it. 

1.  Peabody  Housing  Association  owned  the  development  where  Malika  lived.  However,  I 

heard evidence that Peabody: 

  did not know where its ownership boundary finished; 
  did not risk assess the barrier to the canal; 
  did not act on complaints made by residents about the barrier; 
  having noticed in October 2023 that the barrier was unsafe, did not attempt to make 
it safer and did not make any significant attempt to ask anyone else to make it safer. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  I also heard that when the planning application for the 2015 housing development was 
considered in the first place, no consideration was given to the safety of the barrier as 
part of the development. 

I  have  been  told  that  the  government  has  announced  a  consultation  on  the  national 
planning policy framework (NPPF). I have also been given to understand that section 12 
sets out policies relating to the achievement of safe, inclusive and accessible spaces. It 
has  been  put  to  me  that  paragraph  135(f)  could  include  a  requirement  that  when 
development takes place in proximity to open water, railways and other hazards, special 
regard should be paid to ensuring the safety of children, young people and vulnerable 
adults.  

I outline below a response to this area of concern raised by the Senior Coroner.  

The Mayor’s responsibilities for planning  

The  Mayor  is  required  to  prepare  a  Spatial  Development  Strategy  for  London,  known  as  the 
London Plan. This is a statutory requirement under the Greater London Authority Act 1999 (“the 
in  March  2021: 
Act”).  Here 
https://www.london.gov.uk/sites/default/files/the_london_plan_2021.pdf   

the  current  London  Plan  published 

is  a 

link 

to 

The London Plan, together with each borough’s own Local Plan (and any made Neighbourhood 
Plans covering the area) form the statutory development plan against which planning applications 
are assessed in London. The Mayor’s policies within his London Plan are required by the Act to 
only deal with matters which are of strategic importance to Greater London, leaving the detail 
and specific content to the Local Plans for each respective borough in London which must be in 
‘general conformity’ with the London Plan.   

The  London  Plan  reflects  the  overall  strategy  for  how  London  can  develop  sustainably  and 
contains a number of strategic policies relevant to matters of safety, accessibility and inclusion. 
There is a clear emphasis in the plan on an inclusive approach to accessibility, seeking to ensure 
that  developments  take  account  of  the  needs  of  London’s  diverse  populations,  and  provide 
independent access for all, including, children and young people, older people, disabled people 
and those with other protected characteristics.  

This is an important aspect of policies that relate to design, housing quality and standards and 
social interaction e.g. play and informal  recreation, and aligns with the Mayor’s Good Growth 
objective on building strong and inclusive communities.  There is also a policy related to the use 
and  enjoyment  of  waterways  in  London,  which  seeks  to  protect  and  enhance  inclusive  public 
access to waterways.  

The Mayor’s powers in relation to planning applications 

All planning applications are submitted to the relevant local planning authority within London i.e. 
the 32 borough councils, City Corporation, London Legacy Development Corporation and the Old 
Oak & Park Royal Development Corporation.  

The Mayor is consulted on all planning applications that are of ‘potential strategic importance’ 
(PSI) to London. These are commonly known as ‘referred’ applications. An application is referable 
to the Mayor if it meets the criteria set out in the Town and Country Planning (Mayor of London) 
Order 2008 (the 2008 Order). Once a planning application has been submitted, and if it meets 

 
 
 
 
 
 
 
 
 
 
 
 
 
 the criteria for a PSI application, the local planning authority is required to refer it to the Mayor 
who then has six weeks to provide comments on the application, assessing whether it complies 
with the London Plan policies. This is a consultation response known as Stage One. 

The  application is  then  considered  by  the  local  planning  authority  at  its  planning  committee, 
where  it  decides  whether  to  grant  or  refuse  permission.  Following  its  consideration,  the  local 
planning authority is then required to refer the application to the Mayor for his final decision, 
known as a Stage 2 referral. The Mayor has 14 days to make a decision whether: to allow the 
local planning authority decision to stand; to direct refusal; or to take over the application, thus 
becoming the local planning authority. 

We have looked at the original planning application for the development where Malika lived and 
we do not believe it would have been referable to the Mayor as it would not have met any of the 
criteria for a PSI application. The Mayor does not have any powers to comment or intervene on 
proposals that do not meet the criteria set out within the 2008 Order. Those proposals are the 
responsibility  of  the  local  planning  authority  who  will  assess  the  application  against  the 
Development Plan. 

The National Planning Policy Framework 

The PFD report refers to the possibility of amending the National Planning Policy Framework 
(NPPF),  specifically  paragraph  135(f)  to  potentially  include  a  requirement  that  when 
development takes place in proximity to open water, railways and other hazards, special regard 
should be paid to ensuring the safety of children, young people and vulnerable adults.  

The NPPF sets out the government’s planning policies for England and how these are expected 
to be applied. The NPPF is a material consideration in planning decisions and is also taken into 
account in the preparation of the Mayor’s London Plan. 

It  would  be  the  responsibility  of  the  Secretary  of  State  for  Housing,  Communities  and  Local 
Government  to  consider  any  proposed  changes  to  the  NPPF.  The  PFD  report  refers  to  a 
consultation on the NPPF. This consultation opened on 30 July 2024 and closed on 24 September 
2024 and was in relation to some very specific questions. The Mayor submitted a response to the 
consultation which focused on the strategic aspects of the consultation.  

As the Mayor must taken into account the NPPF in preparation of the London Plan, the Mayor 
would obviously carefully consider any  changes  made to the NPPF by the government in the 
preparation of his next London Plan. 

Proposed changes to the London Plan 

The GLA is currently in the early stages of reviewing the London Plan. The current timescales for 
this include a consultation on a revised London Plan in the second half of  2025, followed by 
examination in public of the revised version in 2026-27, followed by the adoption of the revised 
London Plan in 2027. 

The Mayor will consider the concerns raised in the PFD report through his review of the London 
Plan and members of the public will also have an opportunity to submit any comments as part of 
the consultation. However, as noted above, the London Plan contains strategic and overarching 
policies and does not provide prescriptive detail as to how developments should address specific 
safety concerns relevant to a particular location. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Conclusion 

Please contact me if I can be of any further assistance and thank you for raising your concerns 
with the Mayor.   

Yours faithfully 

Assistant Director of Planning and Regeneration

PREVENTION OF FUTURE DEATH RESPONSE 
ON BEHALF OF PEABODY TRUST  

Introduction & Summary 

1.  On behalf of Peabody, we reiterate our sincere condolences to the family of Malika Hibu 

following her tragic death in February 2024.  

2.  The inquest into Malika’s death in July 2024 found that she died tragically in February 
2024 after falling into Regent’s Canal. We are grateful for the opportunity to address in 
this  Response  four  concerns  raised  by  HM  Senior  Coroner  ME  Hassel  following  the 

inquest in her Prevention of Future Deaths Report dated 7 August 2024. 

3.  Specifically,  we  address  below  the  concerns  identified  in  relation  to  (a)  Peabody’s 
knowledge of the ownership boundary in relation to the canal, (b) risk assessment in 

relation to the barrier to the canal, (c) acting on complaints made by residents about the 
barrier, and (d) follow-up on safety concerns in relation to barrier.  

A.  Identification of Ownership Boundaries 

Existing Policies and Procedures 

4.  As an organisation, we identify the boundaries of the properties we own from our own 
records as well as those held at HM Land Registry. We maintain on our systems property 
shape  files  obtained  from  HM  Land  Registry  and  update  them  in  line  with  quarterly 
updates received from the Land Registry. Where, in the course of a project, the detail of 
boundary ownership appears unclear from our records and the shape files, we refer to 
the deed title. In the vast majority of cases, together these records allow us to definitively 

identify for which land we are responsible.  

5.  We also, as part of any new development process, conduct research, surveys and site 
investigations.  Our  management  of  any  new  development  follows  a  due  diligence 

tracker which prompts title and boundary checks. Naturally, when new land is acquired, 
Peabody also obtains and relies on legal advice and obtains a report on title as to the 

boundaries of the title obtained.  

1 

 
 
 
 
 
 
 
 
 
 Crest Buildings 

6.  In the case of Crest Buildings and the canal barrier, in legal terms, it is not clear from 
the property records at the Land Registry who owns and has responsibility for the barrier 
and the part of the Dock Wall upon which the barrier sits. However, the records relating 
to the transfer of the Crest Buildings site into Peabody’s ownership, and the consents 
and  permissions  required  to  undertake  any  works  affecting  the  Dock  Wall,  provide 

useful guidance. 

7.  The history of the property is as follows: 

(i)  On 31 March 1998, part of the City Road Basin (“the Basin”) was leased for a 
term  of  40  years  from  25  March  1984  to  Islington  Borough  Council  (“the 
Council”). The lease is registered with title number NGL614130 (“the Lease”).  
The Lease required the Council to keep in a good state of repair the whole of the 
Basin “including those parts of the Waterway wall which are included within the 
Property”. The Lease did not sub-divide different parts of the “waterway wall”. 

(ii)  On 10 September 2012, the Canal & River Trust (“CRT”) was registered as the 

proprietor of the “the Basin” (title number NGL823732). 

(iii)  On 24 March 2015, Canal & River Trading CIC (“CIC”) (a company related to 
CRT)  transferred  to  Family  Mosaic  Home  Ownership  Limited  (“Family 
Mosaic”) all of the land contained in title numbers AGL279378 and NGL817307, 
which  in  particular  covers  the  land  at  1  to  98  Crest  Buildings  (“the  2015 
Transfer”). The specific areas of land that were transferred are tinted pink and 
blue on the title plan for AGL279378. 

(iv)  The 2015 Transfer stated that the property transferred to Family Mosaic “does not 
include the Dock Walls.” Ownership of the Dock Walls was therefore retained by 
CIC. The Dock Walls were defined as “the front and back sides of the retaining 
walls  and  false  quays  (if  any)  and  other  banks  and  edges  of  any  waterways 
adjacent to the Property and marked as existing between the points “A” and “B” 
on the Plan.” 

(v)  A note is also recorded on the Register of Title for title number AGL279378 (i.e. 
the relevant part of Crest Buildings), which says: “NOTE: As to the parts tinted 
pink and tinted blue on the title plan the Dock Walls are excluded from the title.” 

2 

 
 
 
 
 
  
 
 
 (vi)  During the development stage for Crest Buildings, Family Mosaic left the barrier 
on the Dock Wall in place on the understanding that Family Mosaic did not own 
that barrier nor any part of the Dock Wall. 

(vii)  In 2017, Peabody merged with Family Mosaic, making Peabody the owner of the 

land at Crest Buildings that was previously owned by Family Mosaic. 

8.  Considering  that  history,  issues  relevant  to  the  responsibilities  of  ownership  and 

maintenance of the barrier and the Dock Wall are:  

(i) 

The Register of Title for the Crest Buildings site explicitly states that “the Dock 
Walls” are excluded from Peabody’s ownership. The Register does not say that 
Peabody owns any part of the Dock Walls.  

(ii)  The 2015 Transfer says that the property which was transferred to Family Mosaic 
and  which  is  now  owned  by  Peabody  “does  not  include  the  Dock  Walls”.  The 
“Dock  Walls”  in  the  Transfer  are  defined  as  “the  front  and  back  sides  of  the 
retaining  walls  and  false  quays  (if  any)  and  other  banks  and  edges  of  any 
waterways adjacent to the Property and marked as existing between the points 
“A” and “B” on the Plan.” It was and is not clear whether the “banks and edges” 
of the waterway which are excluded from Peabody’s ownership include the top 
of the Dock Wall where the barrier sits. It was and is also unclear what the “front 
and back sides” of the retaining walls, which are also excluded from Peabody’s 
ownership, refer to. We understand that, legally, the “sides” of the wall cannot 
mean simply the side “surfaces” of the wall. Taken together, the definition of the 
“Dock  Walls”  appears  to  cover  all  the  relevant  parts  of  the  (structurally 
functioning) wall. We understand that that appears to have been the view taken 
by the Land Registry, because the Register of Title says the entire “Dock Wall” 
is excluded from Peabody’s ownership, without referring to any particular sub-
parts of the wall. 

(iii)  The walls bounding the water along this part of the Basin had been leased to the 
Council and the Council was required to keep all of the walls, without any division 
of particular parts, in good repair. We understand that this suggests ownership of 

those walls was retained by CIC under the 2015 Transfer. 

3 

 
 
 
 
 
 
 
 
 
 (iv) 

It  was  and  remains  the  case  that  any  changes  to  the  barrier  on  the  Dock  Wall 
requires  both  planning  permission  from  London  Borough  of  Islington  and  the 

consent of the CRT/CIC. 

(v) 

In the original planning permission in 2015, the London Borough of Islington had 
stipulated that “no gates, fences, boundary treatments or other barriers shall be 
retained or installed within the site adjacent to the City Road Basin, without the 
prior  written  consent  of  the  Local  Planning  Authority  ...  the  erection, 

construction, improvement, or alteration of a gate, fence, wall or other means of 
enclosure  within  the  site  shall  not  be  carried  out  without  express  planning 
permission.” This is consistent with wider public policy in favour of open access 
to  waterfronts,  and  there  remain  today  many  hundreds  of  housing  estates, 

including residential properties owned by others immediately adjacent to  Crest 
Buildings, which have open access to canals and waterways.  Planning permission 
was granted by the London Borough of Islington on the specific basis that  this 
this waterfront scheme should include a high proportion of affordable homes for 

families. 

(vi)  Under  the  2015  Transfer,  the  CRT  also  maintained  a  right  to  moor  boats  and 
vessels  along  the canal  edge, including  the right to  install, retain  and maintain 

mooring rings and other apparatus in connection with mooring. This excludes any 
right on the part of Peabody to impede access over the Dock Walls. 

(vii)  CRT  in  pre-planning  discussions  since  the  inquest  has  made  clear  that  any 
installation of new railings on the Dock Walls requires a risk assessment to justify 
it, must not damage the Dock Walls, must not hinder emergency access and egress 
from the waterspace, must not impede access to the land or any easements and 
rights reserved over the land, and must adhere to CRT’s Code of Practice.      

9.  The first time CRT indicated to Peabody its view that Peabody owns the barrier and the 
relevant part of the Dock Wall was after the tragic events of February 2024. Similarly, 

the first time Islington Borough Council indicated to Peabody its view that Peabody is 
responsible  for  the  barrier  was  on  16  July  2024,  one  day  before  the  hearing  of  the 

inquest. These views did not address the legal issues surrounding the Register of Title, 
the Transfer Deed and the Lease that we identified, as above.  

4 

 
 
 
 
 
 
 
 
 Proposed Action 

10. For  the  reasons  we  have  set  out  above,  the  uncertainty  concerning  ownership  and 
responsibility for the waterfront  barrier adjacent to Crest Buildings arose because of a 
legally  complex  issue  in  relation  to  how  to  interpret  the  relevant  property  records. 

Peabody did have in place, and continues to maintain, robust procedures to identify and 
record the boundaries of its properties. However, Peabody is determined that, regardless 

of the ownership of the waterfront edge, Peabody will do everything under its control to 
help  prevent  a  tragedy  like  this    from  occuring  again.  We  have  therefore  identified 

learnings in relation to other aspects of our procedures, as we set out below.  

11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to 
work together with all relevant parties to put in place temporary fencing at the canal side 

which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), 
and  has  prepared  proposals  to  install  a  new,  permanent  barrier.    We  note  that  we  are 
instructed  by  CRT  that  any  activity  involving  the  Dock  Walls  or  the  current  barrier 
requires the consent of the CRT which must take into consideration the requirements of 

water users and the rights of the CRT over the Dock Walls and surrounding land. We 
continue to work with them and all other affected parties, including working closely with 

our  residents,  to  implement  a  mutually  agreed  solution  promptly  and  on  a  permanent 
basis.  

B.  Risk Assessment 

Existing Policies and Procedures 

12. Peabody has detailed policies and procedures in place to identify and manage risks at 

the outset from the design and construction stage. In particular: 

(i)  All schemes are required to be designed in accordance with the design principles, 
key  requirements  and  guidance  within  Peabody’s  Design  Guide.  It  is  a  core 
principle of the Design Guide that every resident has the right to see their home 
as a sanctuary and a place of safety. Accordingly, it requires that Design Teams 
consult with Peabody’s in-house Health and Safety Team. 

(ii) 

Peabody’s Standard Employer’s Requirements to which its contractors are held 
include a requirement that proposals for suitable edge protection are  devised at 
the  contractor’s  technical  design  stage.  Proposals  alternative  to  the  preferred 

5 

 
 
 
 
 
 
 systems  are required to  be risk-assessed. Railings are required to  enclose front 
gardens to dwellings where appropriate. 

(iii)  A Design Governance Panel reviews whether proposed schemes meet five Design 
Priorities.  Safety  is  one  those  five  priorities.  Proximity  to  open  water  was 
previously  assessed  as  part  of  that  priority  where  relevant.  Since  the  inquest, 

proximity  to  open  water  and  risk  mitigation  is  now  explicitly  referenced. 
Accordingly, risk assessment of new waterfront properties on a project-by-project 

basis included specific review of water safety and, since the inquest, this has now 
been  specifically  codified  in  our  procedures  to  require  a  water  safety  review 

applying  the  RoSPA  risk  rating  tool.  Such  reviews  consider,  for  example,  the 
installation  of  railings,  use  of  boundary  markers  and  lighting,  incorporation  of 

signage, water safety education, and systems for site monitoring, as appropriate. 
Reviews at the property design stage are then followed up by physical inspection 
and reporting post-construction. 

(iv)  Particular  attention  is  paid  throughout  Peabody’s  policies  to  the  safety  of  play 
areas for children. These are required to be designed  according to best practice, 
specifically  to  meet  the  associated  BS  EN  Regulations,  the  RoSPA’s  Code  of 
Good Practice for Play Areas, and are  inspected by an accredited RPII inspector 

(Register  of  Play Inspectors International)  who  will  issue  a  Post  Installation 
Inspection to define compliance and risk. Peabody’s Design Guide and Standard 
Employer’s Requirements for contractors both require that communal areas such 
as playgrounds and seating areas should be well overlooked and designed to allow 

supervision from nearby dwellings. 

13. In addition, we use a number of strategies to identify risks after residents move into our 

buildings, including: 

(i) 

Post-occupation  evaluations:  We  generally  review  all  newly  constructed 
buildings  and  places  from  a  project-management  and  a  design-quality 

perspective. Data is collected with a view to learning process or design lessons 
for  future  similar  projects.  Approximately  once  per  year,  a  recent  project  is 

identified for an in-depth review with design, project-management, in-occupation 
and resident voice stakeholders. Again, the purpose of the review is to learn and 

incorporate  changes  to  ways  of  working,  design  standards,  management 
preferences and the like for the benefit of future projects as well as any changes 

which might be appropriate for the project in question.  

6 

 
 
 
 
 
 
 (ii)  Regular  block/estate  inspections  and  play  space  inspections:  When  risks  are 
identified  in  the  course  of  our  regular  block/estate  inspections  that  suggest 
specific action is required, these are recorded and progressed electronically under 

our Customer Relationship Management (CRM) case management system. Our 
inspections follow an Estate Inspections Procedure which sets out a systematic 

process  to  ensure  we  are  aware  of  the  conditions  of  our  estates,  and  that 
inspections  are  tracked  and  managed.  The  Procedure  specifically  covers  an 

inspection of health and safety in relation to play spaces, as well as the condition 
of fencing and gates. 

(iii)  Safeguarding awareness: This addresses protective actions that we must take to 
prevent individuals to whom Peabody has a duty of care from experiencing harm. 
Anyone concerned about the welfare of one of our residents  can raise an alarm 
by making a referral to us, and we explain to residents how they can do so via our 
website. Our staff are made aware of the need for safeguarding and we have a 

dedicated  staff  member  appointed  as  the  Head  of  Centre  of  Excellence  for 
Safeguarding  to  oversee  cases  and  maintain  high  levels  of  awareness.  We 

maintain carefully developed safeguarding policies for both children and adults.  

(iv)  A  complaints  procedure  by  which  residents  can  seek  action  on  particular  risks 

they identify or concerns they have: see below. 

(v)  An Accident and Incident Policy: This includes logging and learning from near 

misses. 

(vi)  A further Risk Assessment Policy on hazards and risks in the workplace, which 

includes our estates.   

Crest Buildings 

14. In the case of Crest Buildings, the design and construction of the property was overseen 
at the time by Family Mosaic, and Family Mosaic obtained planning permission for the 
property.  We  are  not  aware  that  any  concern  was  raised  as  to  excessive  risk  from 

proximity  to  the  waterfront  during  the  planning  permission  stage;  instead,  as  set  out 
above, the planning conditions required open access to the waterfront to be maintained. 

Family  Mosaic  worked  on the understanding  that,  in light  of the legal  understanding 

7 

 
 
 
 
 
 
 
 
 about ownership (also set out above), the barrier did not belong to them and they could 
not obstruct access to the waterfront.  

Proposed Action 

15. While robust risk assessment and management procedures identified above are already 
in  place  within  Peabody,  we  keep  our  practices  under  regular  review  and  have 

considered further insight from the tragic incident in February 2024. We are therefore 
updating our Design Guide and our Standard Employer’s Requirements for contractors 
to include, as a check-list item, an explicit requirement to conduct risk assessments of 
adjacency to water and similar hazard types from the design stage onwards. This will 

reference  a  requirement  for  both  a  design  review  of  proposals  and  planned  risk 
mitigation, and also a post-installation inspection. We plan to finalise and embed these 
changes within the Employer’s Requirements by 31 January 2025.  

16. In addition, in accordance with advice from RoSPA, an audit is being conducted across 
Peabody estates to inform the formation of a Water Safety Policy across the group to 

ensure  that  water  risk  assessment  guidance  is  properly  tailored  to  the  needs  of  our 
organisational  context.  Work  on  this  document  is  already  under  way  in  co-operation 

with the RoSPA, and we plan to finalise this policy following completion of work on 
the Employer’s Requirements.  

C.  Complaints Procedures 

Existing Policies and Procedures 

17. We  have  a  clear  complaints  policy  and  procedure  that  set  outs  how  we  approach 
complaint  recording  and  processing.  This  is  aligned  to  the  Housing  Ombudsman’s 
Complaint Handling Code.  

18. Residents  are  informed  of  the  policy  and  procedure,  in  particular  how  to  register 
complaints so that they can be appropriately logged and actioned, when they move in to 
our buildings and more information can be found at any time on our website or through 

calling  our  customer  helpline.  In  line  with  the  policy  and  procedure,  we  record  all 
complaints submitted in this way in our CRM case management system. Our staff are 

trained on providing formal complaint responses in line with the Housing Ombudsman 
Complaint Handling Code.  

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 19. We  also  receive  a  large  number  of  informal  enquiries  and  communications  from 
residents,  for  example  on  routine  site  visits  by  Neighbourhood  Managers.  Where 

appropriate, these are also recorded and processed  using our CRM case management 
system.  As  an  organisation,  our  staff  record  and  progress  many  such  enquiries, 

especially those where follow-up tasks are identified.  

Crest Buildings 

20. No formal enquiries or complaints were submitted by residents in relation to the safety 
of the canal side barrier at Crest Buildings. We understand however that, in 2019, an 
informal concern was raised about the barrier to the then Neighbourhood Manager on a 

routine site visit. The then Neighbourhood Manager considered that it was not possible 
to block off the canal side barrier in view of what was understood about the planning 

conditions,  the  policy  of  the  Council  to  maintain  open  access  to  the  waterfront,  and 
Peabody’s lack of ownership rights over the barrier. We understand that it is because 
she  considered  no  action  was  possible  and  the  concern  was  raised  informally  in  the 
course of a site visit when various other enquiries and issues will also have been raised, 

that  the  issue  as  to  the  barrier  was  not  formally  logged  for  processing  on  the  CRM 
system. 

Proposed Action 

21. In this case, therefore, there was a formal complaints processing system in place,  but 
this issue  was not further actioned for the reasons stated above. We are satisfied that the 

various improvements we have made to our complaints systems, processes and culture 
since 2019 (both to comply with the Housing Ombudsman Code and to reflect our own 

learning) mean that  no additional changes are required to  our complaints system  and 
processes  at  this  point..  However,  we  are  strengthening  our  processes  for  near 

miss/hazard reporting (see below). 

D.  Follow-Up on Safety Risks 

22. On  31  October  2023,  consistent  with  Peabody’s  policies  under  which  staff  members 
routinely visit and inspect its properties to keep safety issues under review, a Peabody 
staff  member  conducting  a  routine  visit  at  Crest  Buildings  identified  that  additional 

waterfront fencing may be required. Because of the understanding that Peabody did not 
own  the  barrier  or  the  Dock  Wall,  he  communicated  his  concern  to  the  Council  and 
sought the Council’s assistance. No response was received from the Council. Our staff 

9 

 
 
 
 
 
 member then chased a response on 9 February 2024. Regrettably still no response to the 
issue was received from the Council before the tragic incident on 17 February 2024. 

23. As with the issues above, we have carefully considered learnings from these sad events 
and have  therefore reviewed our policies and practices to  ensure  that safety  risks  are 
identified  at  an  early  stage  and  that,  once  identified,  they  are  monitored  and 

appropriately mitigated. We note that the reason the concern as to the barrier was not 
further actioned in this exceptional case was because of the understanding, in view of 

the legal considerations set out above, that the barrier did not belong to Peabody and 
that the waterfront could not be obstructed. As set out above, we do have a robust Estate 

Inspection Procedure, a Complaints Policy, a Risk Assessment Policy, and an Accident 
and Incident Policy, which would otherwise ensure that such concerns are logged and 

followed-up.  Nevertheless,  we  plan  to  raise  awareness  with  our  staff  members  and 
provide additional guidance that safety observations such as those identified in this case 
should be formally logged under our existing policies, procedures and systems. We plan 
to do this by 31 October 2024. As noted, we are also taking steps in coordination with 

the  RoSPA  to  ensure  that  waterfront  risks  are  appropriately  identified  and  actioned 
across our estates with a further Water Safety Policy.  

Concluding Remarks 

24. We hope this Response and the actions identified above demonstrate that Peabody takes 

all safety concerns seriously. 

25. We reiterate that this tragic case arose from a combination of factors. There have been 
issues  around  ownership  and  planning  with  conflicting  interests  concerning  public 
access to the canal (as required by the London Borough of Islington), access and egress 

to the water (as required by CRT/CIC), and the safety of residents at Crest Buildings. 
The particular legal complexity in relation to ownership of the waterfront barrier is not 
common to other Peabody properties. On the other hand, planning conditions and public 
policy  in  favour  of  open  access  to  the  waterfront  are  common  and  well-established 

across  the  country,  and  there  are  many  hundreds  of  housing  estates,  including 
residential properties owned by others immediately adjacent to Crest Buildings, which 

have open access to canals and waterways.  

26. As explained above, acting on the basis that, as stated in HM Land Registry’s title for 
the  property,  the  Dock  Walls  did  not  belong  to  Peabody,  and  being  aware  that  the 
conditions  of  our  planning  permission  restricted  any  obstruction  of  the  waterfront 

through new railings or fencing, in October 2023 we raised our concern with the Council 

10 

 
 
 
 
 
 
 about the adequacy of the existing barrier and sought the Council’s assistance. We were 
conscious  that  the  Council  had  firmly  required  clear  access  to  the  waterfront  for  the 

public as part of its planning consent, and that residential properties owned by others 
immediately adjacent to Crest Buildings do not have any barrier at the water’s edge at 
all. Obstructing the waterfront without the approval of the Council would have risked 
serious legal breaches of our planning permission.  Despite the concern we raised, we 

were not advised that anyone took the view prior to the tragic events of February 2024 
that we had the legal right to install any new barrier on the Dock Walls and to obstruct 

access to the waterfront as we may have considered.  

27. Since the tragic events of February 2024, in addition to the strengthening of policies and 
approaches described above, Peabody has taken swift steps to put in place emergency 
temporary  fencing  and  develop  more  permanent  safety  features  at  the  canal  edge.  In 

particular, we have prepared proposals for the installation of new protective railings. We 
have been instructed, however, that this requires approval from (and changes to various 

legal agreements  with) both the London Borough of Islington and the CRT/CIC. We 
continue to  work  with  them and all other affected parties, including  our  residents, to 

enable  Peabody  to  commission  the  design,  construction  and  implementation  of  a 
mutually agreed solution promptly and on a permanent basis.  

28. We remain deeply saddened by the events of 17 February 2024, and repeat our sincere 

condolences to Malika’s family. 

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