Alexander Cardoza
Response Status
Report Content
Coroner
I am Alison Hewitt, HM Senior Coroner for the City of London.
Legal Powers
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I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Investigation and Inquest
I have commenced an investigation into the death of Alexander Cardoza. The investigation has not yet been concluded.
Circumstances of Death
On the evidence currently available to me, I understand that Alexander Cardoza, a child aged 16 years, died on the 27 th March 2025, after falling from [REDACTED] in the City of London. The [REDACTED] is owned and operated by [REDACTED]. [REDACTED] is owned by [REDACTED] and [REDACTED] and operated and managed by [REDACTED].
Coroner's Concerns
The evidence I have gathered to date reveals matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows :
- On the 10
th December 2024, I concluded the inquest in to the death of [REDACTED] and found that he died on the [REDACTED] after [REDACTED].
- Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over [REDACTED] fall to his death on the 27
th March 2025.
- It seems that no or no sufficient action has been taken to prevent persons being able to fall [REDACTED] and that there is an ongoing risk of further deaths. The ongoing risk is exacerbated by the fact that there have now been two deaths in similar circumstances, thereby increasing the risk of others copying.
- I am particularly concerned that, despite previous knowledge of the risks,
(i) the barriers in place [REDACTED] remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) [REDACTED] can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27 th March 2025 was insufficient to prevent Alexander Cadoza from surmounting the barrier and falling, and (v) there is no CCTV security camera [REDACTED] in place.
Action Required
In my opinion immediate action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation have the power to take such action.
Your Response
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You are under a duty to respond to this report within 56 days of the date of this report, namely by the 29 th May 2025 . I, as 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.
Copies and Publication
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I have sent a copy of my report to the Chief Coroner and to the Interested Persons and other organisations listed below which may find it useful or of interest : [REDACTED], parents of Alexander Cardoza City of London Planning Department and Environment Department City of London Licensing Team City of London Police I am also under a duty to send the Chief Coroner a copy of your response. 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. She may send a copy of this report to any person who she 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 by the Chief Coroner.
Investigation and Inquest
rd April 2025 Alison Hewitt
Details
- Report Date
- 3 April 2025
- Coroner
- Alison Hewitt
- Coroner Area
- City of London
- Reference
- 2025-0210