Recurring concern

Inadequate suicide-prevention signage at public locations

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First reported 30 Jun 2015•Latest report 13 Jan 2020

Definition

What this concern includes

Includes failures of signage at public-access locations specifically intended to provide suicide-prevention or Samaritan support information, including absent, insufficient, poorly positioned, obscured or inadequate signs that may prevent people from recognising or accessing available help.

Not included

Excludes the existing narrower concern limited to suicide-prevention signage at railway stations when the assertion is confined to that railway-station setting.
Excludes general warning, wayfinding or emergency signage where suicide-prevention or Samaritan support is not the identified purpose.
Excludes broader suicide-prevention service, crisis-response or mental-health access failures where the signage control itself is not deficient.
Excludes physical suicide-prevention barriers, CCTV, lighting or other environmental controls unless the assertion specifically identifies inadequate suicide-prevention signage.

Reports: 4
Individual concerns: 4
Date range: 2015–2020
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Isle of Wight Council2

The National Trust For Places Of Historic Interest Or Natural Beauty2

Bedford Borough Council1

Hammerson PLC1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

13 Jan2020
Isle of Wight
Concerns raised1
1. Lack of suicide-prevention signage providing the Samaritans telephone number at Tennyson Down
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.
  Stated by National Trust – Isle of WightStated planned
2. Action
  Conduct a full internal review of suicide-prevention measures after completing the planned stakeholder meetings.
  Stated by National Trust – Isle of WightStated planned
AI-generated summary

Annette Jane Lewis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Annette Jane Lewis died after throwing herself from a cliff at Tennyson Down while in acute distress and behaving unusually. The concerns identified were the absence of fencing at the cliff edge and the lack of signs directing people in mental distress to support such as the Samaritans.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of suicide-prevention signage providing the Samaritans telephone number at Tennyson Down
Wider context from the report
“1. I heard evidence from ████████ that there are no fences to protect the public from falling over the edge of the cliff at Tennyson Down, and moreover that there are no signs providing those in some sort of mental distress with the number for the Samaritans. Whilst I acknowledge that putting fences around the edge of the cliff would be a massive undertaking by the landowners, it may prevent a future death if those who are in extremes are reminded that there are people out there who are trained to assist them at that time. 2. Having just concluded a similar inquest involving a woman who threw herself from the top of Culver Cliff where I raised similar concerns with both the National Trust and the Director of Public Health who heads up the Suicide Prevention Group on the Isle of Wight, it seems appropriate that if consideration is being given by these organisations to better signage being implemented at the top of Culver Cliff, at the same time, consideration can also be given to making similar improvements at Tennyson Down. ”
Source location
Annette Jane Lewis · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.

Verbatim wording from the response
“2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with ████████ from the group has been scheduled for Friday 3rd April 2020 to conduct site visits to both Culver and Tennyson Downs.”

Source location
2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a full internal review of suicide-prevention measures after completing the planned stakeholder meetings.

Verbatim wording from the response
“6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate.”

Source location
2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
Page 2 · response
Published 8 February 2020
Open published response
31 Dec2019
Isle of Wight
Concerns raised1
1. Unavailability of suicide prevention signs at Culver Cliff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Maintain seven Samaritans signs at Culver Down.
  Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated completed
2. Action
  Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.
  Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated planned
3. Action
  Conduct a full internal review of suicide-prevention measures after the planned meetings.
  Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated planned
AI-generated summary

Joanna Sarah Louise Orpin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Joanna Sarah Louise Orpin experienced severe, treatment-resistant agitated depression before leaving home on 13 February 2018 and disappearing near Culver Cliff. Her body was found on mudflats at Bosham Quay on 18 February 2018, and the inquest concluded that she killed herself. The substantive concerns included recurring incidents involving people in mental distress at Culver Cliff and the apparent absence of suicide-prevention signs there.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of suicide prevention signs at Culver Cliff
Wider context from the report
“2. I was also informed that whilst there used to be signs at the top of Culver Cliff akin to those which are found at Beachy Head in East Sussex and the Itchen Bridge in Southampton which have wording such as “Suicidal? Despairing? Call Samaritans on [local number]”, these signs appear to no longer be present. (Since the Inquest, I have been provided with the following proof that these signs once existed from ████████: https://www.alamy.com/culver-down-uk-07th-july-2018-a-samaritans-sign-on-the-edge-of-culver-cliff-on-the-isle-of-wight-uk-reads-talk-to-us-if-things-are-getting-to-you-posted-after-a-spate-of-suicides-from-the-same-spot-yachts-can-be-seen-passing-in-the-background-during-the-round-the-island-yacht-race-on-the-hottest-recorded-day-of-the-year-so-far-at-33-degrees-celsius-credit-matthew-blythealmy-live-news-image211378076.html ) 3. During the course of his evidence, Inspector ████████ told the Inquest that he had made recommendations for these signs to be displayed approximately 3 years ago, and he was aware that a Consultant Psychiatrist had made similar recommendations within the last 12 months. Concerns had been ventilated in relation to how many signs would be required and at what intervals. It was the opinion of Inspector ████████ that just a small number of strategically placed signs (perhaps in the car park, and at various intervals along the length of the fence as well as at places where it is easier to cross the protective fence at the kissing gate) would be adequate – in his words, “If they save just one life, then it would be worthwhile.” I agree with his views. 4. I also heard evidence from ████████, a Consultant Psychiatrist at the Isle of Wight NHS Trust that he sits on a Suicide Prevention Group, and they had also tried to get these signs reinstated at the top of Culver Cliff, to no avail. ”
Source location
Joanna Sarah Louise Orpin · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain seven Samaritans signs at Culver Down.

Verbatim wording from the response
“I can confirm that a number of measures were already in place at Culver Down, including a total of seven Samaritans signs placed within the past few years. A schematic showing the locations of these signs is at Annex A. In addition, ‘dragons teeth’ (wooden bollards to prevent vehicle access) are in place opposite the exits from the car park and there is a ditch to ground vehicles approaching the cliff edge. There is also a barbed wire fence running the”

Source location
2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
Page 1 · response
Published 8 January 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.

Verbatim wording from the response
“2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with ████████ from the group has been scheduled for Friday 3rd April 2020 to conduct site visits to both Culver and Tennyson Downs.”

Source location
2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
Page 2 · response
Published 8 January 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a full internal review of suicide-prevention measures after the planned meetings.

Verbatim wording from the response
“6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate.”

Source location
2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
Page 2 · response
Published 8 January 2020
Open published response
13 Aug2018
Bedfordshire and Luton
Concerns raised1
1. Insufficient availability and visibility of Samaritans signs
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Carry out a full audit of signage across the multi-storey car parks, including Samaritans signage.
  Stated by Bedford Borough CouncilStated planned
AI-generated summary

Stephen James LAWSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephen James LAWSON, aged 62, was witnessed jumping from the fourth floor of the Luke Street Multi Storey Car Park in Bedford and died at the scene. Concerns included the ease of accessing the external barrier wall, the ability to use the crash barrier to cross it, the history of previous jumps, and the limited visibility of Samaritans signs.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient availability and visibility of Samaritans signs
Wider context from the report
“(4) There are very few ‘Samaritans’ signs, and these generally are only visible if a pedestrian is exiting the car park ”
Source location
Stephen James LAWSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Carry out a full audit of signage across the multi-storey car parks, including Samaritans signage.

Verbatim wording from the response
“There is some signage located within the MSCPs that promote the services of the Samaritans for persons that may need to use their confidential counselling services. Nevertheless, I have requested that a full signage audit be carried out as is set out below.”

Source location
2018-0264-Response-by-Bedford-Borough-Council
Page 4 · response
Published 4 October 2018
Open published response
30 Jun2015
South London
Concerns raised1
1. Insufficiency of notices advising visitors of Samaritans services
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Colette Hughes · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Colette Hughes died on 7 July 2014 after jumping from the top storey of a multi-storey car park at Centrale Shopping Centre in Croydon. Concerns were raised that the accessible perimeter wall had been involved in at least two previous deaths, posed a danger to people using it as seating, and that notices about Samaritans services might not be sufficient without physical modifications.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficiency of notices advising visitors of Samaritans services
Wider context from the report
“The wall is easy to access and at least two previous deaths have occurred in similar circumstances since 2006. Whilst recognising that barriers cannot be provided at every location above ground, and the fact that the building complies with regulations , there is a concern that others may die in the same manner. There is also a concern that the wall presents a danger to those who may decide to use it as a seating area, particularly after taking drink or drugs. In the absence of some physical modifications, the notices advising visitors of the services of the Samaritans recently installed may not be sufficient. ”
Source location
Colette Hughes · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of suicide-prevention signage providing the Samaritans telephone number at Tennyson Down

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Unavailability of suicide prevention signs at Culver Cliff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Insufficient availability and visibility of Samaritans signs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Insufficiency of notices advising visitors of Samaritans services

Actions described in response 2

Actions described in response 3

Actions described in response 1