May 19, 2025

Alexander Cardoza: Prevention of Future Deaths Report

Child Death (from 2015)Suicide (from 2015)

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Date of report: 03/04/2025

Ref: 2025-0210

Deceased name: Alexander Cardoza

Coroners name: Alison Hewitt

Coroners Area: City of London

Category: Child Death (from 2015) | Suicide (from 2015)

This report is being sent to: Samba London Limited | Heron Property Corporation Limited

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: 1. [REDACTED], Company Secretary of Samba London Limited, and 2. [REDACTED], Company Secretary of Heron Property Corporation Limited (also for and on behalf of Pavilion Trustees Limited and Pavilion Property Trustees Limited)
1	CORONER I am Alison Hewitt, HM Senior Coroner for the City of London.
2	CORONER’S LEGAL POWERS 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.
3	INVESTIGATION and INQUEST I have commenced an investigation into the death of Alexander Cardoza. The investigation has not yet been concluded.
4	CIRCUMSTANCES OF THE 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 Samba London Limited. [REDACTED] is owned by Pavilion Trustees Limited and Pavilion Property Trustees Limited and operated and managed by Heron Property Corporation Limited.
5	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 : 1. On the 10^th December 2024, I concluded the inquest in to the death of Abel Solomon Hadgu and found that he died on the 17th November 2022 after [REDACTED]. 2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did [REDACTED] fall to his death on the 27^th March 2025. 3. 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. 4. 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.
6	ACTION SHOULD BE TAKEN 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.
7	YOUR RESPONSE 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.
8	COPIES and PUBLICATION 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.
9	3^rd April 2025 Alison Hewitt

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