Alexander Cardoza

28 May 2025 

Dear Ms Hewitt, HM Senior Coroner for the City of London 

Regulation 28 Report, dated 3 April 2025 - Re: Alexander CARDOZA (deceased) 

We write in response to your Regulation 28 Report, dated 3 April 2025.  

We would like to take the opportunity to express our deepest condolences to the family and friends of 
Mr Cardoza. 

takes the safety and security of its customers very seriously.  Working in conjunction 
with  the  landlord 
(the 
"Landlord"), we regularly conduct safety risk assessments and audits, with the help of external expert 
advisers, and upgrade where appropriate the premises and operational processes.  

Following  careful  consideration  of  the  matters  raised  in  the  Regulation  28  Report,  we  respectfully 
provide the following response. 

The 

leases the 
Landlord and has done since March 2011.  

has two 

 from the 

The Landlord is responsible for the structure 
control  over  the  operation  of 
collaboratively together in respect of safety and security.  

has full day-to-day 
(including  decorating  and  furnishing).    We  work 

 and 

Previous Incident and Subsequent Action Undertaken  

The Regulation 28 Report references the previous (and only other) sudden non-suspicious death at 
, which at the time had 
1.39m  high  glass  balustrades,  compliant  with  Building  Regulation  requirements  (being  1.10m).  Mr 
Cardoza passed away after 
, which was the first 
and only incident 

in November 2022. This incident occurred at 

. 

By early 2023, the following action had already been taken in respect of 

: 

1.  Fencing was added 

glazing balustrade increasing its height to 2.4m. The 
already had the additional fencing so had balustrades of that 2.4m height when 
the  incident  occurred.  This  is  significantly  higher  than  the  minimum  height  stipulated  for 
balustrades in the Approved Document Part K of the Building Regulations. 

2.  All seating backing onto the balustrades were removed to prevent individuals approaching the 
has never had any seating backing directly 

balustrade directly. 

onto the balustrades and did not at the time of this recent incident.  

 
 
 
 
 
 
 
 
 3.  Processes  were  also  updated  so  that  in  addition  to  having  a  member  of  our  staff  always 
also  has  a  dedicated  security  guard 

present  whenever  it  is  accessible, 
present from 3pm onwards to monitor the perimeter area.   

These  changes  were  following  a  Risk  Assessment  report  we  prepared  with  the  Landlord  (who  we 
understand had appointed a health and safety consultant to provide advice in this regard), following 
, and finalised on 16 February 2023.  
an analysis 

Current Position 

will 
At present, 
not be opened until the balustrades have been increased to a height of at least 3m. We are working 
with the Landlord to progress this but do not have an exact timeframe at this stage.  

is also padlocked shut. 

remain closed.  

Following  consultations  with  external  advisers  (Citation  (Health  &  Safety  Consultants),  the  City  of 
London  police  and  City  and  Hackney  Public  Health  team)  once 
are  reopened,  the 
following operational changes will be in effect: 

1.  When 

reopen, all furniture will either be fixed to the floor and will not be able to 
be moved or for certain items such as chairs and other seating which require some movement 
to be usable, these will be secured to the floor using chains.  No furniture will be close to the 
balustrades, and it will not be possible to move any freestanding furniture to the balustrades.   

2.  Training: 

a. 

training  was  provided  to  Heads  of  Department  staff  on  14 
December 2022 and in March 2023 and then refresher courses were provided on 14 
June 2024 and 27 May 2025.   

b.  Prior  to  reopening  of 

,  all  staff  working  for 

will  receive 
training  on 
(regardless  of  their  role)  and  this  training  will  be 
 (as recommended 
refreshed on a biannual basis. We have already asked 
by the City of London Police) to train existing staff members so that they are better 
 red flags. All new staff members will be required to complete 
prepared to spot 
training on our E-learning platform before they can begin 
internal 
.  
working at 

c.  All outsourced security staff will also be required to have completed 

and intervention training prior to working for us.  

3.  Staff and security member present on 

: 

a.  At the time of this incident, there were three staff members working 

.  

There is always at least one staff member working 

when open.  

b.  As noted above, 

always has a security guard present monitoring the 
balustrades when open from 3pm onwards and an additional security guard controlling 
from 3pm 
access to 
daily during peak business times as agreed with the Landlord, so was therefore not 
there at the time of the incident. 

itself. A security guard monitors the

 
 
 
 
 c.  We are awaiting a final risk assessment report from Citation which we expect to receive 
shortly. In conjunction with all the other steps undertaken, this will consider whether 
further staff or security measures need to be put in place and we will adjust protocols 
further to their recommendations in due course as necessary.  

4.  CCTV covers both 

and has done since 

resulted 
were opened. At the time of the incident, the angle of the cameras on
in a blind spot. We have since adjusted the camera angles to improve coverage, and the CCTV 
system now covers approximately 95% of 
. The CCTV at the premises is (and 
has always been) compliant with the terms of our licensing requirements and we cannot in fact 
add any more cameras as we have reached the limit of the system.  

We do not address any changes to the physical structural barriers in any detail here as the Landlord 
is taking steps to upgrade these. The plan is to upgrade the balustrades to a height of at least 3m and 
make  them  solely  of  strengthened  glass  but  this  is  subject  to  planning  constraints  and  structural 
implications regarding anticipated wind loads.  

will remain closed while this design process continues, and the Landlord will be able to 
expand  further  on  these  plans.  We  will  continue  to  support  the  Landlord,  but  we  cannot  comment 
further on the decision-making process behind the changes that were made and continue to be made.  

In  the  longer  term, we,  in  conjunction with  the  Landlord,  have planning  permission  to permanently 
enclose 
. We are in the process of agreeing the terms and process for doing this with 
the Landlord.  

Conclusion 

of process changes which will immediately come into effect once 
with the Landlord in respect of the safety of 

.  

takes safety and security extremely seriously.  It has already implemented a number 
reopen and is working 

Along with the Landlord, we will continue to monitor the effectiveness of the proposed changes and 
will make further operational upgrades should it be necessary to do so, working with external experts 
as appropriate.  

We trust the additional information set out above helps address any concerns that the Coroner has 
regarding the operational safety of 

.  

Yours sincerely,

Via E-mail and post

FAO Alison Hewitt

HM Senior Coroner for the City of London
4" Floor

The Central Criminal Court Old Bailey
City of London

EC4M 7EH

22 May 2025

Dear Coroner

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS:
REGARDING THE DEATH OF ALEXANDER ADNAN CARDOZA

1. INTRODUCTION

1.1 We confirm receipt of your report to prevent future deaths issued on 3 April 2025 (the
“Notice”), made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 following the death
of Alexander Adnan Cardoza on 27 March 2025. A response is required by 29 May 2025 to

deal with the concerns raised within the = _

1.2 We would like to express our deepest sympathies to the family and friends of Alexander,
following his untimely death,
De
1.3 This response is given as per the requirements under Regulation 29 of the Coroners
(investigations) Regulations 2013.

2. THE NOTICE AND BROADER CONCERNS

2.1 We note the coroner has outlined the following concerns in the in the Notice.

(0) The barriers in place Renan surmountable;

(ii) The barriers include horizontal metal wiring which, it appears, may assist the surmounting

of the barrier;
(iii) The (qgiean be moved and can be used to assist a person to surmount the
barriers;

2.2

3.2

3.3

3.4

3.5

(iv)

(v)

The nature and level of the operational security in place on the 27 March 2025 was
insufficient to prevent Alexander Cardoza from surmounting the barrier and falling; and

There is no CCTV Camera monitoring

As such the coroner has requested that immediate action be taken to prevent future deaths by
addressing the concerns set out above and that both Heron Property and Samba are in a
position of power to take such action.

BACKGROUND AND PROPERTY INFORMATION

For ease of reference and to assist the coroner, we outline the position regarding the arca of

concern to the coroner. Se

29

i: the tenant for the operation of their business as a SN cased
the premises in shell condition and completed their own full fit out. GB 2s full and sole
responsibility for the operation of the business trading at the premises which includes ti!

QE including ensuring health and safety compliance.
EE responsible for the management of the property including the structure

and the barriers a'r alt

Following the death of Alexander Adnan Cardoza, i addressing the

concerns raised by yourself at (i) and (ii) by demonstrating the primary actions being taken to

alleviate those concerns. The concerns raised at (iii), (iv) and (v) are within (J remit but

we are working with fimmim to find an adequate and timely solution for the safe use of
HE 1d outline our response to these concems also.

Balustrade (referred to here as barrier(s)) heights within the built environment are governed
and directed from Approved Document Part K of the Building Regulations, which stipulate
that at any commercial or residential property, the barrier height shall be set at a minimum
height of 1.1m from the finished floor level.

The original barriers on J were over and above the building regulations
compliance requirement of 1.1m at the time of practical completion. The barrier on the Hi
as extended to 2.4m by way of metal wires to prevent customers from dropping
«the side directly onto the pavement below.

barrier was also increased to 2.4m by way of metal wires, following the death of Mr Hadgu.
‘ES id not have these modifications made at the same time as the ||
; beyond the MM there is a flat roof preventing any dropped
fr from falling to the ground.

3.7 The Notice states, “Jt seems that no or no sufficient action has been taken to prevent persons

from being able to fal from a 2 this

is “despite the subsequent structural and operational changes” outlined in the inquest on 10

December 2024. As was submitted by iIimmmmigant the inquest, there were additional
metal wires installed on iii as there had previously been installed on

the EF urther, a full risk assessment was conducted by
and this included information on the necessary operations of the [J including security and

HE fortunately, it is evident these operational risk management

controls were not being followed on the day of 27 March 2025. The position is therefore, that

HEE 24 taken action following the inquest in December 2024 to further prevent
persons from being able to climb over and subsequently fall fron

3.8 It is also respectfully noted that, in both incidents, individuals appear to have taken deliberate

actions to bypass and surmount the barriers QM}. rather than having accidently
fallen from them, as might be misconstrued from the above concern.

3.9 The metal wires currently \aiaiieteeiaeiees) BENE e intentionally not
taut (i.e., causing them to bend towards the direction of pull) so to make it harder, but not
impossible to climb, however, it is understood by HE. at further preventative
measures need to be taken to stop individuals from surmounting the barriers.

3.10 For ease, we have dealt with the actions in response to the coroner’s Notice in two parts,
addressing each {individually as different actions are being taken in respect of each

ME © ost appropriately deal with the risk presented.

4. PROPOSED STRUCTURAL CHANGES iii

41 HEE 325 2 boundary barrier comprising of glass with a stainless-steel frame at
1.39m high. There are additional metal wires to increase the height of the barrier to 2.4m. The

additional metal wires were added at the point of installation, the reason being to
prevent/avoid customers from standing against {
a neeennienaiommniniy £21! to the pavement below.

4.2 In response to concern (i), EEE «< progressing a project in conjunction with ma
to permanently enclose [as

43 Planning permission was previously granted in 2015 by City of London for a full enclosure
to fr including fully enclosed sides. The planning consent lapsed in the
meantime.

44 GEE b2ve now received a detailed proposal from Scheldebouw which allows fora
modular steel framed enclosure to {he additional structure will have a roof
with an electric louvre system to allow for ventilation but will fully enclose xy

45 Tha been agreed y EE (uly cnclosine IAs th
best solution and Scheldbeouw were formally instructed on 13 May 2025 to produce the

detailed designs.

4.6

47

4.8

5.2

5.4

5.5

5.6

5.7

As the design is still in the developmental stage and whilst the structural and wind calculations
have taken place, the design will have to go through a planning application process and
approval would also be needed from Mr Russell Pengelly, the Design Out Crime
Officer/Architectural Liaison Officer (ASB/Crime Prevention Advisor) prior to the planning

application being submitted. :: in contact with Mr Pengelly.
The exact timescales for this project are unknown as it is in the design and planning phase.
GEE: <pects this would take at last 12 months. This will remove the need for

horizontal metal wires and deals with concern (ii) as regards (The structure
will no longer be surmountable.

In the meantime, we understand that i keep the P| closed to the public

until permanent alterations have taken place and Js enclosed.

PROPOSED STRUCTURAL CHANGES TO [a

As outlined above, following the death of Mr Hadgu, it was concluded that the metal wires
would be effective to increase the height of the barrier, thereby making it significantly more
difficult to climb over the barrier. The additional height by way of metal wires was added by
March 2023.

Whilst (EE was not relevant to the unfortunate incident on 27 March

2025, |NNN Understands the importance of making further structural changes in
addition to those made in March 2023, to further prevent persons from being able to surmount

the barriers.
In response to concern (i), HR ave progressing designs to increase the height of

Po] barrier and change nature of the barrier, by removing the horizontal

metal wires, IN have now received a detailed proposal from Scheldebouw which
increases the height of the barrier from 2.4m (1.39m glass, with the metal wires extending it
to 2.4m) to 2.8m whilst also removing the handrails and footrails. In this design the existing
glass and base brackets will remain in situ and new 2.8m posts will be installed to support
new glazing that will be added to increase the height of the barrier to 2.8m. The barrier will
therefore be made up completely of glazing up to a height of 2.8m.

amma ES that the structural alterations to PF will be
completed by Autum 2025.

Scheldebouw have carried out preliminary design works and modelling for this location, but
it will require further development throughout the proposed 5-week pre-construction phase to

finalise the drawings and specifications.

This will alleviate the need for horizontal metal wires and deals with concer (ii) as regards
CC
| informed us that (I il aso remain closed to the public

until permanent alternations have taken place to the barrier.

5.8

5.9

6.2

63

6.4

Again, such recommendations for alternations to the design of the barriers need to be signed
off by Mr Russell Pengelly, the Design Out Crime Officer/Architectural Liaison Officer

(ASB/Crime Prevention Advisor). As outlined above i are in contact with Mr
Pengelly and he has been invited to the kick-off call with Scheldebouw which is scheduled to

take place in May 2025.

As per the recommendations in the Public Health report, post installation of the approved
design changes, a plan will be set up to allow officers to revisit and follow up with a
ensure safety is upheld.

OTHER CONCERNS ee SECURITY AND CCTV)
It has been identified that the as well as the (resent

a risk as it mitigates the height of the barriers when lowards the
barriers, presenting a platform to climb onto the barriers.

It has been recommended in the Public Health report that J remove these gigas
Hs 200 kept away from the edgesyuigmgs It has been
suggested that ma obtain alternative designs for the hii They are

focusing on © place and away from the edges to prevent people from
SE 2 2, providing greater security. RM understands that

will seek alternative designs to remove the risk the current layout presents and to deal with
concern (iii) raised by the coroner, in conjunction with heightening the barrier on

nd permanently enclosing fr

As regards concern (iv) the ee: responsible for and provide security personnel for the
ee
As regards concern (v) whilst there is CCTV covering (the risk assessment

established that neithe i CTV covers (iy
The Public Health report comments that “Whilst this is not a breach of the licensing condition
attached to the premises licence, the CCTV should cover all operational areas.” It has been
agreed that the Licensing Team will work with to enhance coverage once the design
and build is more advanced and potentially refresh the condition attached to the licence by
way of minor variation. Such designs will take account of the umbrella placements to ensure
this does not block CCTV coverage iii! PF do not propose increasing
their CCTV coverage in this areas as review and actioning anything seen on the CCTV in real
time would present practical issues i.c., IM)security who are based on the ground
floor would not have direct contact with [IHEEEbnd would be too far away to act in an
emergency situation.

RELEASE OF THE RESPONSE / PUBLICATION OF RESPONSES

Our instructed solicitors CMS Cameron McKenna Nabarro Olswang LLP (“CMS”) contacted
the coroner on 4 April 2025 as regards the publication of the Notice and any responses. The
concern raised at the time was to invite the coroner not to publish the Notice in the immediate

future as doing so may encourage copycat attempts.

8.2

We are grateful for the coroner’s agreement that the Notice will not be published in the
meantime. Upon publication of the Notice and responses, for the same reasons, we would
invite the coroner to extensively redact the information within to avoid a member of the public
from reviewing them and establishing how to circumvent any control measures in place at the

CONCLUSION
We thank you for your time taken to prepare the Notice and for permitting us to review the

information provided.

HR i! continue to engage with the necessary parties to ensure that changes are
made in an expedited manner to achieve safe and compliant roof terrace areas.

Yours sincerely