Recurring concern

Inadequate slip resistance on stairs

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First reported 9 Oct 2014•Latest report 19 Dec 2023

Definition

What this concern includes

Includes failures or hazards involving inadequate slip resistance on stairs, including smooth or worn stair surfaces, absent non-slip treatment and comparable surface conditions on communal, residential, public or operational stairways.

Not included

  • Excludes general walking-surface trip hazards where inadequate slip resistance on stairs is not the identified condition.
  • Excludes road, pavement and path surfaces unless the assertion specifically concerns stairs.
  • Excludes stair access-control, supervision, lighting, glazing, handrail and fall-arrest deficiencies where slip resistance is not the unsafe condition.
  • Excludes isolated falls without an identified continuing deficiency in stair-surface slip resistance.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Gravesham Borough Council1
Home Group Limited1

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.

  1. North West Kent

    AI-generated summary

    Richard HEDGES · 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

    Richard Hedges was admitted to critical care after an unwitnessed fall down a short external staircase, resulting in cardiac arrest, traumatic cervical spine fractures and extensive hypoxic brain injury. He was later moved to comfort care and died on 26 September 2023. Concerns related to the staircase included worn concrete steps without a non-slip surface or edge highlighting, a handrail that was too short, and poor lighting.

    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

    Failure to maintain a slip-resistant external staircase surface

    Wider context from the report

    “(1)The short external staircase where Mr Hedges fell is constructed of concrete steps which are showing signs of wear/weathering. The steps are not coated with a non slip surface and the edges of the steps do not have highlighting to increase awareness. ”

    Source location

    Richard HEDGES · 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

    Remove the steps and platform from the walkway to return it to ground level.

    Verbatim wording from the response

    “I am writing in response to the above Regulation 28 report, to provide details of works undertaken to address your concerns following the conclusion of the inquest into the sad death of Mr Hedges. An action plan was drawn-up immediately following the inquest to determine what works should be carried out to address your concerns and the timescale for these works to be undertaken. A copy of the Action Plan is attached for your information. The decision was taken to remove the steps and platform completely and bring the walkway back to ground level thereby removing the hazard posed by the steps and also improving access to the bins for wheelchair users.”

    Source location

    Response from Gravesham Borough Council
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Completed works are considered sufficient to address all concerns raised in the Regulation 28 report.

    Verbatim wording from the response

    “During the inquest my officer mentioned that there was another similar structure on the same estate which only had access from steps at one end. These steps have also been removed along with the platform bringing access back down to ground level. The final tarmac floor finish in this area is due to be completed over the next few days. Gravesham Borough Council believes the works undertaken address all the concerns raised in the Regulation 28 report. If you require any further information or clarification, please do not hesitate to contact me.”

    Source location

    Response from Gravesham Borough Council
    Page 2 · response
    Published 29 December 2023

    Open published response

  2. North Northumberland

    AI-generated summary

    Stephen Peter Simpson · 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 Peter Simpson appears to have fallen down communal concrete stairs on 13 March 2014 and struck his head on an external door, later dying in hospital from a skull fracture and brain haemorrhage. The concerns were that the building had no lobby or passageway to arrest a fall and that the smooth concrete stairs lacked a non-slip surface, leaving a risk of serious injury or death from impact with the door.

    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 a non-slip surface on communal stairs

    Wider context from the report

    “The design of the building is that there is no entrance lobby or passageway to arrest any accidental fall, with the result that any person who slips or falls while negotiating the communal stairs is liable to sustain serious injury from making impact with the solid external door. Additionally, the stairs are constructed of smooth concrete without the addition of any non-slip surface. Even if a non-slip surface was present, this would not obviate the risk of serious injury or death from impact with the external door, if a person falls from the stairs. ”

    Source location

    Stephen Peter Simpson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026