Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0014, written 10 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2025 |
|---|---|
| Reference | 2025-0014 |
| Deceased | Joshua Forsdyke |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Joshua James David Forsdyke (died 31 August 2024)
THIS REPORT IS BEING SENT TO:
1. Fresh Student Living
2. University of the Arts, London
1
CORONER
I am: Melanie Sarah Lee
Assistant 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 10 September 2024 an investigation was commenced into the death
of Joshua James David Forsdyke “Josh” (aged 19). The investigation
concluded at the end of the inquest on 8 January 2025. I made a
determination at inquest Joshua took his own life whilst his judgment was
impaired due to drugs and alcohol.
4
CIRCUMSTANCES OF THE DEATH
Josh moved to London to study in September 2023. He was exposed to
easy access to drugs, particularly ketamine, whilst in student halls of
residence. He began buying ketamine and his addiction to illicit drugs
and alcohol appears to have spiralled from there and continued when
he moved out of halls. On 26 August he took ketamine and had an
argument with his girlfriend about his drug use. The following day, he
began drinking alcohol in the morning, before taking tramadol tablets
belonging to a third person. He then left the flat and went to London
Bridge, telling his flat mate that he intended to jump. After behaving
bizarrely on the bridge, he jumped into the River Thames. His body was
1
recovered from the Thames near Butlers Wharf on 31 August 2024.
Toxicology tests showed that Josh had consumed a significant level of
alcohol, a toxic of tramadol plus ketamine, shortly before his death.
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.
I heard evidence that Ketamine was easily and openly available to
students as it was being dealt from and/or by persons with access to,
and moved between, student halls of residence.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that your organisations 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 6 March 2024. I, the coroner, may extend the
period.
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.
• Family of Joshua Forsdyke
• HHJ Alexia Durran, the Chief Coroner of England & Wales
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.
2
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 ASSISTANT CORONER
10 January 2025
3
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Ms Lee, 03rd March 2025 Thank you for your Regulation 28 report to prevent future deaths dated 10th January about the death of Joshua Forsdyke. I am replying as the Managing Direct of Fresh Property Group with responsibility for Fresh Student Living. Firstly, I would like to say how saddened I was to read of the circumstances of Joshua’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. I understand your concern about him being exposed to drugs while in student halls of residence. As a father of two, one being at second year of university this is a concern every parent shares. I note that you have also addressed these matters of concern to the University of Arts London, and we liaise closely with them to ensure a smooth delivery and good tenant experience. We are contracted to the University of Arts London for the delivery of specific services in three of their halls of residence and are working with them on this specific matter. Fresh Property Group separately to the University of Arts operate as a third-party manager on over fifty private student buildings across the country and have ~19,000 residents. As a company we take anti- social and illegal behaviour very seriously and this is evident in our policies, procedures and training with our teams. Unfortunately, in our society the use of illegal drugs is prevalent across all different social groups from professionals to students. We operate amongst this challenge and when identified we report suspicious activity to the police and Universities. In the past in certain cities, we have entered into tri-party data sharing agreements as we look to work with police to root out any residents that be conducting illegal activities. We rely on working with the local police and their prioritisation of resource; however, we have examples when the police support with tours of the properties and even the use of search dogs. Most of our residents are over the age of eighteen, meaning they are considered adults under the law. The tenancy agreements they sign give them the same rights as any other adults renting a property, regardless of age. This is their home, and as a management team, we are mindful of that. We always seek permission before entering and carry out periodic inspections of the living areas, ensuring everything is running smoothly. In direct response to your Regulation 28 report, we are doing the following in response to reduce the likelihood of future deaths: 1) In conjunction with University of Arts a) Review of room inspections to focus more on signs of illegal drug use. These visual inspections are completed three times a year and currently focus on H&S and compliance. 12 Soho Square, London, W1D 3QF thisisfresh.com 020 3617 4430 Registered Company No: 07268209 VAT No: 142 9205 28 b) Drug awareness training has been part of the standard training suite already by UAL and Fresh teams. We will ensure this continues. c) Whilst Joshua was not a resident in a Fresh managed hall of residence during his first or second year. During this period, there were no reports of drug dealing by any of our residents that we were made aware of or could have been acted upon. I understand the inquest heard evidence that suggests a dealer was potentially operating from our halls, so we do take this report seriously. Fresh and UAL will ensure where concerns are raised, data is shared between Fresh and UAL teams, specifically the Out of Hours team and UAL and the overnight security cover at Fresh. d) Fresh does not hold the tenancies with residents at our UAL partnered halls of residence, these are held by UAL, and all induction and tenancy information are conveyed to students by the University. Fresh and UAL collaborate on an awareness campaign to make it explicit to students where to report signs of drug misuse and dealing at halls of residence. e) A question will be added to the annual student survey asking students if they are aware of where to notify if they believe drug dealing is taking place in their halls of residence 2) Across Fresh Property Group a) Where overnight contracted security is present at Fresh properties, all guards hold valid SIA licences. This means Guards are trained in identifying drug misuse and signs of drug dealing. Fresh ensure that all security assignment instructions with our security partners are reviewed annually. b) Fresh currently has robust policies relating to drug dealing, and we take Zero tolerance approach at our properties. Fresh will continue to review these policies and refresh them. We believe properties managed by Fresh operate overall in a safe and compliant manner that gives students a home they can enjoy and feel safe within. We have been recognised in the sector for doing just that and it is our purpose that we continue to do so. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours Sincerely Managing Director 12 Soho Square, London, W1D 3QF thisisfresh.com 020 3617 4430 Registered Company No: 07268209 VAT No: 142 9205 28
Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 6 March 2025 Dear Ms Lee, Response to Prevention of Future Deaths Report I write on behalf of University of the Arts London in response to the Prevention of Future Deaths report dated 10 January 2025, related to the death of Joshua James David Forsdyke. My response summarises the actions we are taking in the operation of our halls of residence in respect of use and distribution of illegal drugs, with the aim of preventing future deaths. I am also submitting with this letter our detailed action plan. We recognise the challenges created by the ease with which students can obtain illegal drugs in London, through access to suppliers who deal drugs in the neighbourhoods where our halls are located and in external social environments, as well as through postal delivery of illegal drugs purchased through the dark web. We are committed to providing a safe, secure and supportive living environment for our students. The plan details actions we are taking to enhance prevention, identification, awareness, support, monitoring, and enforcement, working with key partners, including the police and safer neighbourhood teams, health promotion organisations, purpose-built student accommodation providers and our student community. The key objectives of our action plan are to: • Reduce the availability of illegal drugs in halls of residence by improving identification of drug dealing activity and delivery of drugs by parcel post and strengthening partnerships with the police and safer neighbourhood teams. We want to reassure students and deter drug dealers and drug use. • Raise awareness of the risks associated with drug and alcohol use and reduce misuse of drugs and alcohol. • Enhance our monitoring, support and reporting systems within our halls of residence to identify and act on drug dealing and to assist students at risk, providing support for students struggling with substance misuse. • Promote a culture of safety, security, responsibility and wellbeing through clear policies, regular training for staff and our communication with students. University of the Arts London 272 High Holborn, London WC1V 7EY • Extend our approach to active listening by introducing questions about drugs and alcohol use in our Resident Satisfaction Survey, to better understand student concerns and take effective action based on their responses. I believe this response and the attached action plan provides the information requested. If you require further details, please contact me. Yours sincerely Dean of Students
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