Concerns raised 1
Failure to prevent unrestricted and unguarded public access to a vertical drop View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kay Wilson · 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
Kay Wilson drowned shortly after 23:30 on 6 December 2025 after accidentally passing through a gap in a protective stone wall near County Bridge in Barnard Castle, falling approximately 9 metres onto rocks and then into the River Tees. The principal concern was that the breach provided unrestricted and unguarded access from a public area to the vertical drop and river below.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to prevent unrestricted and unguarded public access to a vertical drop
Wider context from the report “A breach in the stone wall running north above the riverside from the east side of “County Bridge", Barnard Castle, provides unrestricted and unguarded access from a public area to a vertical drop of approximately 9 metres onto rocks and the River Tees below . ████████
” Source location Kay Wilson · Prevention of Future Deaths report
Open source report
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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 Install a steel fence section to close the riverside wall gap and prevent unrestricted access to the drop.
Verbatim wording from the response “• In relation to the breach in the stone wall running north above the riverside from the east side of "County Bridge" it has been agreed that the most appropriate permanent control measure is the installation of a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below.” Source location 2026-0132 - Response from Durham County Council
Open published response
23 Oct 2025 Mr Saranveer Singh Sihota · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Relatively low perimeter wall creating a risk of fatal falls View source
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.
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AI-generated summary
Mr Saranveer Singh Sihota · 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
Mr Saranveer Singh Sihota, known as Sunny, was a detained patient at a mental health unit who left without permission and died from injuries sustained after falling approximately 70 feet. The report identifies concerns about the relatively low perimeter wall at the location, the risk of fatal falls, and the possibility that others experiencing suicidal thoughts might use the location.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Relatively low perimeter wall creating a risk of fatal falls
Wider context from the report “It is reported to me that the ████████ has a relatively low wall to it . Given the height of the top floor there appears to be a clear risk that, either deliberately or accidentally, people might fall to the ground with high chance of death . I am not aware of what barriers there may be to the perimeters of the lower floors.
” Source location Mr Saranveer Singh Sihota · Prevention of Future Deaths report
Open source report
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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 Closed the car park’s top floor to the public using temporary fencing.
Verbatim wording from the response “Chesterfield Borough Council undertook a full investigation following the tragic death of Mr. Sihota, focusing on what measures could be taken to prevent future death or injury. ████████ first opened in 1981, with all floors including the top floor being used for car parking. Following Mr. Sihota’s death, the top floor of the car park was closed to the public immediately utilising temporary fencing.” Source location Response from Chesterfield Borough Council
Open published response
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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 Installed a permanent enhanced closure comprising full-height heavy-duty gates and fencing to prevent unauthorised access to the top floor.
Verbatim wording from the response “A full closure scheme with enhanced suicide prevention measures was then developed to prevent any unauthorised access to the top floor permanently. This included the installation of full height, heavy duty gates and fencing. The permanent enhanced closure for the top floor of the car park was completed in March 2024. The following photos have been supplied to show the suicide prevention measures installed:” Source location Response from Chesterfield Borough Council
Open published response
Concerns raised 1
Insufficient physical barriers or impediments preventing public access from the platform to the hazardous area View source
This report raised 2 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.
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AI-generated summary
Jody Lee ROBB · 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
Jody Lee ROBB died at 23:03 on 8 April 2025 on the carriageway of Station Approach after taking deliberate steps to end her own life. Concerns included insufficiently restricted access from the station platform and the possibility that her presence was not detected or reported by train crews or station staff, despite 11 trains passing during the preceding hour.
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× 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 physical barriers or impediments preventing public access from the platform to the hazardous area
Wider context from the report “I read and heard evidence from the investigating CID officer who had reviewed all available
CCTV in relation to the incident. She reported that Jody had arrived on the south bound
platform just over an hour before she jumped. She sat on a bench for a few minutes before
making her way onto ████████. She was on the
████████ for about one hour before she actually did so. A total of 11 trains passed her, north
and southbound, during that hour. No report was made or received of her presence there
by train crews of station staff attending on the station platforms for arrivals and departures.
████████. My concerns are:
1. Access to the ████████ from the platform is not sufficiently barred or impeded to the
public. It is clear by means of signage that the public must not go beyond the end of the
platform. There are what appear to be some sort of wheeled access steps overs on the
platform at and around the fence at its end. But there is nothing to prevent even a
moderately mobile person from going around the fence and ████████. The main
resource preventing access is human by means of station staff intervention, which is
necessarily reliant on their presence at the relevant time;
2. ████████ are not ones designed to prevent, impede or discourage
attempts at suicide
████████████████████████████████████████████████████████████████
3. Eleven trains passed Jody, from north and south, while she was on ████████ during
the hour before she jumped. No reports were made by any train crew of her presence. It
would be exceedingly the available evidence and unfair to infer that train crews and/or
station staff deliberately or negligently ignored her presence there. More likely is that she
was simply not visible. It was dark, being at night in April, and Jody was wearing relatively
dark clothing. However, she seems to have been discernible on CCTV and from the British
Transport Police images I have seen taken from approximately where a driver might have
been placed, it is plausible to suggest that she might have been visible, even laterally, from
the cab of a train either slowing to stop at the station or pulling out from it, even in
deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her
presence, some type of intervention could have been attempted ████████████████████
████████.
” Source location Jody Lee ROBB · Prevention of Future Deaths report
Open source report
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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 Provide a locked, climb-resistant gate restricting unauthorised access from the platform toward the track and viaduct.
Verbatim wording from the response “The end of the platform is fitted with a locked gate, and beyond this, there is a drop off the edge of the platform to track level, to deter individuals from walking beyond the platform’s edge and onto the track. Access via the locked gate is granted only for authorised personnel. The gate is the standard design and has pointed tops, to make it difficult for individuals to climb over the gate. The gate does not extend to the platform edge, as this is in compliance with Network Rail’s national standards.” Source location 2025-0330 Response from Network Rail
Open published response
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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 Install anti-trespass rubber pyramid mats along the track and viaduct edges as physical and visual deterrents.
Verbatim wording from the response “Near the end of the platform and at the side of the gate referred to above there are anti-trespass rubber pyramid mats (“witches hats”) which extend along the edge of the railway track onto the viaduct for approximately 60 metres, on each side of the station platform. This is beyond what is required by Network Rail’s standards. The intention of the witches hats is to make access difficult for anyone intending to trespass by acting as both a physical and visual deterrent.” Source location 2025-0330 Response from Network Rail
Open published response
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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 Operate an automatic warning message directing people away from the platform end.
Verbatim wording from the response “There is an automatic voice message released from a speaker, when individuals get within 14 metres of the end of the platform. This tells people to move away from the platform end.” Source location 2025-0330 Response from Network Rail
Open published response
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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 Develop and secure remaining approval for mesh safety panels to increase and curve the viaduct parapet inward.
Verbatim wording from the response “As the viaduct is a Grade 2 listed structure, Network Rail is required to submit a listed building consent application and prior approval planning application before it can undertake any work to physically alter the existing viaduct structure. Without the Council’s approval, we would be unable to carry out any works to the existing viaduct structure which alter its appearance.” Source location 2025-0330 Response from Network Rail
Open published response
3 Apr 2025 Alexander Adnan Cardoza · Prevention of Future Deaths report City of London
View report summary
Concerns raised 3
Failure of barriers to prevent surmounting View source Barrier design incorporating horizontal metal wiring that may assist surmounting View source Failure to prevent movable objects being used to assist barrier surmounting View source
This report raised 2 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Alexander Adnan Cardoza · 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
Alexander Adnan Cardoza, a 16-year-old child, died on 27 March 2025 after falling from a location in the City of London. The principal concerns were that barriers remained surmountable, could potentially be assisted by horizontal wiring and a movable object, and that operational security was insufficient to prevent the fall; there was also no CCTV security camera monitoring of the location. The report identifies an ongoing risk of further deaths, noting that two deaths had occurred in similar circumstances.
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× 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 of barriers to prevent surmounting
Wider context from the report “1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████.
2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025.
3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ 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 ████████ remain surmountable , (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place.
” Source location Alexander Adnan Cardoza · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Barrier design incorporating horizontal metal wiring that may assist surmounting
Wider context from the report “1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████.
2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025.
3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ 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 ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier , (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers, (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place.
” Source location Alexander Adnan Cardoza · Prevention of Future Deaths report
Open source report × 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 prevent movable objects being used to assist barrier surmounting
Wider context from the report “1. On the 10th December 2024, I concluded the inquest into the death of ████████ and found that he died on ████████ after jumping from ████████.
2. Despite the subsequent structural and operational changes I was told about at the inquest, Alexander Cardoza was able to and did climb over ████████ and fall to his death on the 27th March 2025.
3. It seems that no or no sufficient action has been taken to prevent persons being able to fall from ████████ 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 ████████ remain surmountable, (ii) the barriers include horizontal metal wiring which, it appears, may assist the surmounting of the barrier, (iii) the ████████ can be moved and can be used to assist a person to surmount the barriers , (iv) the nature and level of operational security in place on the 27th March 2025 was insufficient to prevent Alexander Cardoza from surmounting the barrier and falling, and (v) there is no CCTV security camera monitoring of ████████ in place.
” Source location Alexander Adnan Cardoza · Prevention of Future Deaths report
Open source report
16 Jan 2025 Alexander Charles Edward Thomas · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3
Failure to prevent access to the eastbound motorway crash barrier via a fixed metal ladder View source Lack of fencing preventing access over the eastbound motorway crash barrier View source Failure to prevent access from the pedestrian walkway to the eastbound motorway crash barrier via a ramp-like structure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Charles Edward Thomas · 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
Alexander Charles Edward Thomas died on 14 August 2024 after entering the eastbound carriageway of the M56 motorway and being struck by a heavy goods vehicle. Concerns included accessible routes from a pedestrian walkway and track to the motorway's crash barrier, and a lack of fencing to prevent access onto the motorway along that stretch.
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× 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 prevent access to the eastbound motorway crash barrier via a fixed metal ladder
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway.
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway .
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” Source location Alexander Charles Edward Thomas · Prevention of Future Deaths report
Open source report × 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 fencing preventing access over the eastbound motorway crash barrier
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway.
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway.
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway , in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” Source location Alexander Charles Edward Thomas · Prevention of Future Deaths report
Open source report × 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 prevent access from the pedestrian walkway to the eastbound motorway crash barrier via a ramp-like structure
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway .
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway.
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” Source location Alexander Charles Edward Thomas · Prevention of Future Deaths report
Open source report
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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 Assess with electrical and maintenance teams whether remote cabinet access is feasible, whether carriageway ladder access is essential, and what health and safety requirements apply.
Verbatim wording from the response “In addition, we are in discussion with our Electrical team and Maintenance contractors to establish if it is feasible to maintain a more remote access to the electrical cabinets and whether direct access from the mainline carriageway, via the ladder, is essential. This includes the relevant health and safety requirements and if this can be resolved we will take steps to remove the ladder from the retaining wall. Again, if this is feasible the work will be completed by 30 June 2025.” Source location Response from National Highways
Open published response
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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 Repair and extend boundary fencing around the hotel car park, Hasty Lane and the structure’s wing walls to reduce access to the carriageway.
Verbatim wording from the response “We will repair the boundary fence both at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure to increase the security and reduce access to the area along the carriageway. This work will be completed by the 30 June 2025.” Source location Response from National Highways
Open published response
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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 Completely preventing determined pedestrian access to the Strategic Road Network is impossible, although fencing and compliant design provide deterrence and security.
Verbatim wording from the response “The M56 motorway at this point spans Hasty Lane which forms an underpass to facilitate access by cyclists and pedestrians. The structural supports and cast concrete wing walls mirror the profile of the embankments on either side of the motorway and are located within the highway boundary. This design of ‘bridge’ complies with the design requirements outlined within the Design Manual for Roads and Bridges and includes tubular railings to protect against falls from the structure. It is accepted that this type of design does not deter determined attempts by pedestrians to gain access to the motorway but when combined with timber boundary fence provides some deterrence and security. By the very nature of the Strategic Road Network, it is impossible to fully deny access.” Source location Response from National Highways
Open published response
11 Sep 2024 Emma Victoria HARPER · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to provide bridge barriers preventing pedestrians from easily climbing over and falling from the bridge View source
This report raised 2 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.
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AI-generated summary
Emma Victoria HARPER · 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
Emma Victoria HARPER died on 4 May 2024 after falling from a footbridge onto a crash barrier beside the M602 motorway; the inquest concluded that her death was suicide. Concerns were raised that the bridge had not been included in works to increase barrier heights or otherwise prevent people at risk from falling onto the motorway, and that the basis for its exclusion was unclear.
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× 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 provide bridge barriers preventing pedestrians from easily climbing over and falling from the bridge
Wider context from the report “1. During the course of evidence it was stated that the foot bridge which the deceased fell from had not been considered suitable for amendments to be made to the level of barrier which would prevent a pedestrian crossing the bridge from easily climbing over and falling onto the highway below .
2. Other bridges in the locality were considered and selected for an increase in the height of the barrier or other works to prevent the risk of falling from the bridge onto the M602 motorway.
3. It was unclear on what basis the foot bridge that the deceased fell from has been excluded from such works and there is a risk that this bridge may still be accessed by people who may be at risk of falling as an alternative to other bridges were works had been undertaken in the locality.
” Source location Emma Victoria HARPER · Prevention of Future Deaths report
Open source report
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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 Complete a study of suicide-related issues at bridges and structures along the M602 route.
Verbatim wording from the response “In relation to the M602 a study of suicide related issues along the route was undertaken in 2022, specifically in relation to the number of incidents occurring at bridges and structures spanning the route. The ████████ footbridge that you have raised as a concern was one of eight structures included in this assessment. It was identified that an increase in parapet fence height from the standard 1 metre to 1.8 metres was a potential intervention but noted that the boundary is difficult to effectively secure around the bridge itself. The footpaths along ████████ and ████████ which run for several hundred metres alongside and above the M602 have concrete boundary walls of approximately the same height as the existing bridge parapet fence.” Source location Response from National Highways
Open published response
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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 Increase parapet fence heights to 1.8 metres at six bridges with the highest numbers of suicide-related incidents.
Verbatim wording from the response “During the current road investment period (2020-25) in the North West region we have increased parapet fence heights to 1.8 metres at six of our bridges with the highest number of suicide related incidents. These are ████████ and ████████ over the M60 in ████████, ████████ and ████████ at Junction █ of the M60, and ████████ and ████████ over the M56 in Wythenshawe.” Source location Response from National Highways
Open published response
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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 Available funding and achievable benefits constrain parapet upgrades, so locations with the highest number of incidents are prioritised.
Verbatim wording from the response “Increasing the parapet fence height from the standard 1 metre to 1.8 metres can cost up to £1m per bridge. In addressing concerns surrounding these sites we are constrained by the available funding and the benefits that can be achieved. We therefore prioritise locations with the highest number of suicide related incidents. This is the reason that some bridges have already received upgraded parapets, as historically they have exhibited a far higher level of risk. An example in this area is ████████ which crosses the M602 adjacent to ████████.” Source location Response from National Highways
Open published response
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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 No parapet-height increase is currently proposed because the footbridge recorded three incidents, none causing injury or fatality, during the assessment period.
Verbatim wording from the response “When assessing the available information relating to suicide related incidents along the M602, there were three recorded at the ████████ footbridge during the five-year study assessment period from 2017 to 2021, none of which had resulted in an injury or fatality. We therefore currently have no proposals to increase the parapet fence height at ████████ footbridge.” Source location Response from National Highways
Open published response
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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 National Highways is responsible for considering remedial works because the bridge structure, parapets and retaining walls are its assets.
Verbatim wording from the response “Salford City Council have been in discussion with National Highways regarding this matter. They confirmed that the bridge structure, parapets and retaining walls on ████████ are National Highway assets. As such we believe they are looking into the feasibility of remedial works at this location following this recent incident.” Source location Response from Salford Council
Open published response
7 Aug 2024 Malika HIBU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3
Failure to make an identified unsafe barrier safer or secure its remediation View source Failure to risk assess the canal barrier View source Inadequate canal-side railing protection for children and adults View source
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.
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AI-generated summary
Malika HIBU · 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
Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.
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× 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 make an identified unsafe barrier safer or secure its remediation
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer .
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” Source location Malika HIBU · Prevention of Future Deaths report
Open source report × 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 risk assess the canal barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal ;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” Source location Malika HIBU · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate canal-side railing protection for children and adults
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it .
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” Source location Malika HIBU · Prevention of Future Deaths report
Open source report
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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 Install and maintain temporary canal-side fencing inspected by RoSPA.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with relevant parties to approve, design, construct and implement a permanent canal-edge protective barrier.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Peabody to progress a planning application for safety fencing around the canal-side area of the Crest Buildings Estate.
Verbatim wording from the response “In terms of the Crest Buildings housing development, the Council is working proactively and positively with Peabody to bring forward a planning application for safety fencing around the canal side area of the Estate. The Council has held two senior level meetings with Peabody to discuss their planning application and to encourage them to submit the application in the most expedient manner possible. Once the application is submitted, we will deal with it promptly. We have also met with the residents of the Estate to explain the planning process and to encourage them to engage in that process.” Source location Response from Islington Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require explicit water-adjacency and similar-hazard risk assessments, design reviews, mitigation planning and post-installation inspections in design guidance and contractor requirements.
Verbatim wording from the response “15. While robust risk assessment and management procedures identified above are already in place within Peabody, we keep our practices under regular review and have considered further insight from the tragic incident in February 2024. We are therefore updating our Design Guide and our Standard Employer’s Requirements for contractors to include, as a check-list item, an explicit requirement to conduct risk assessments of adjacency to water and similar hazard types from the design stage onwards. This will reference a requirement for both a design review of proposals and planned risk mitigation, and also a post-installation inspection. We plan to finalise and embed these changes within the Employer’s Requirements by 31 January 2025.” Source location Response from Peabody Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an estates audit and develop a group Water Safety Policy with RoSPA to tailor water-risk assessment guidance.
Verbatim wording from the response “16. In addition, in accordance with advice from RoSPA, an audit is being conducted across Peabody estates to inform the formation of a Water Safety Policy across the group to ensure that water risk assessment guidance is properly tailored to the needs of our organisational context. Work on this document is already under way in co-operation with the RoSPA, and we plan to finalise this policy following completion of work on the Employer’s Requirements.” Source location Response from Peabody Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require project-specific waterfront water-safety reviews using the RoSPA risk-rating tool in new-property procedures.
Verbatim wording from the response “(iii) A Design Governance Panel reviews whether proposed schemes meet five Design Priorities. Safety is one of those five priorities. Proximity to open water was previously assessed as part of that priority where relevant. Since the inquest, proximity to open water and risk mitigation is now explicitly referenced. Accordingly, risk assessment of new waterfront properties on a project-by-project basis included specific review of water safety and, since the inquest, this has now been specifically codified in our procedures to require a water safety review applying the RoSPA risk rating tool. Such reviews consider, for example, the installation of railings, use of boundary markers and lighting, incorporation of signage, water safety education, and systems for site monitoring, as appropriate.” Source location Response from Peabody Trust
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Regulator of Social Housing assessed Peabody against regulatory standards and concluded that no further regulatory action was required.
Verbatim wording from the response “The Regulator of Social Housing has engaged directly with Peabody in relation to this tragic case and having assessed all relevant information against regulatory standards, has now concluded no further regulatory action will be taken. However, the Regulator will continue its regular engagement with Peabody and note the steps that Peabody is taking in response including working with other parties to address issues raised in the Prevention of Future Deaths notice.” Source location Response from MHCLG
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Peabody considered it unable to block or alter the barrier because it lacked ownership rights and understood planning conditions prohibited obstructing waterfront access.
Verbatim wording from the response “20. No formal enquiries or complaints were submitted by residents in relation to the safety of the canal side barrier at Crest Buildings. We understand however that, in 2019, an informal concern was raised about the barrier to the then Neighbourhood Manager on a routine site visit. The then Neighbourhood Manager considered that it was not possible to block off the canal side barrier in view of what was understood about the planning conditions, the policy of the Council to maintain open access to the waterfront, and Peabody’s lack of ownership rights over the barrier. We understand that it is because she considered no action was possible and the concern was raised informally in the course of a site visit when various other enquiries and issues will also have been raised, that the issue as to the barrier was not formally logged for processing on the CRM system.” Source location Response from Peabody Trust
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Peabody sought the Council’s assistance because it understood the Council or CRT/CIC held responsibility for the barrier and Dock Wall.
Verbatim wording from the response “(iii) The walls bounding the water along this part of the Basin had been leased to the Council and the Council was required to keep all of the walls, without any division of particular parts, in good repair. We understand that this suggests ownership of those walls was retained by CIC under the 2015 Transfer.” Source location Response from Peabody Trust
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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 Installing new protective railings requires approval and changes to legal agreements involving the London Borough of Islington and CRT/CIC.
Verbatim wording from the response “11. Since the tragic incident on 17 February 2024, Peabody has also taken prompt action to work together with all relevant parties to put in place temporary fencing at the canal side which has been inspected by the Royal Society for the Prevention of Accidents (RoSPA), and has prepared proposals to install a new, permanent barrier. We note that we are instructed by CRT that any activity involving the Dock Walls or the current barrier requires the consent of the CRT which must take into consideration the requirements of water users and the rights of the CRT over the Dock Walls and surrounding land. We continue to work with them and all other affected parties, including working closely with our residents, to implement a mutually agreed solution promptly and on a permanent basis.” Source location Response from Peabody Trust
Open published response
23 Jul 2024 Frederick Barrie Dunbavin · Prevention of Future Deaths report Dorset
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Concerns raised 1
Absence of a barrier between the wooded area and the pathway View source
This report raised 2 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Frederick Barrie Dunbavin · 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
Frederick Barrie Dunbavin, who had dementia and periods of confusion, fell from a wooded area at the Treetop Apartments onto a concrete path and sustained multiple injuries that caused his death. Concerns related to open access to the wooded area, the absence of a barrier and warning signage at the drop, and the continuing risk of life-threatening injuries.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a barrier between the wooded area and the pathway
Wider context from the report “1. During the inquest evidence was heard that:
i. There is open access from the carpark area at The Treetops Apartment complex to the wooded area that Mr Dunbavin accessed before he fell. In addition, there is no barrier between the edge of wooded area and the pathway that runs to the rear of the church hall . Finally, there is no signage to warn that there is a dangerous drop from the edge of the wooded area onto the path below.
2. I have concerns with regard to the following:
i. Mr Dunbavin sustained multiple injuries following a fall from the wooded area at the Treetops Apartment complex, having accessed the wooded area from the parking area. There was nothing that prevented him from accessing this area, or warning him of the drop from the wooded area. I understand that no changes have been made subsequent to Mr Dunbavin’s death. Therefore, there remains a risk that access can be easily gained to this area, with a risk of life-threatening injuries should anyone fall from the wooded area to the path below.
” Source location Frederick Barrie Dunbavin · Prevention of Future Deaths report
Open source report
1 May 2024 Laura Gawthorpe · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to provide complete fall-prevention fencing and barriers at car park levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Laura Gawthorpe · 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
Laura Gawthorpe, a voluntary patient at the Becklin Centre in Leeds, left on escorted leave on 13 September 2022 and deliberately fell from a car park, dying instantly from unsurvivable injuries. The report raised concern that fencing and barriers were only partially installed at the level from which she fell, leaving a parapet wall that could still easily be climbed over.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide complete fall-prevention fencing and barriers at car park levels
Wider context from the report “(1) The evidence of West Yorkshire Police was that, by the erection of extensive fencing and barriers, measures have been put in place on levels ████████ at the car park to make it harder for people to fall from those levels, whether deliberately or accidentally.
(2) The erection of similar measures on level ████████ has been only partial. The point from where Mrs Gawthorpe fell was identified by correlating her location on the ground with the location on level ████████ where she had left her phone before her fall. At that location, the parapet wall could still easily be climbed over.
” Source location Laura Gawthorpe · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procure and install additional physical barriers at identified upper-floor locations and throughout the car park.
Verbatim wording from the response “Since receiving your report we have been working very closely with a range of partners, including The Samaritans, Leeds City Council Public Health, and internal colleagues including Leeds Building Services, (our internal building services team), health and safety, communications, and our design and architecture technical consultants at Norse Consulting Ltd. to deliver a range of new prevention measures in relation to suicide at ████████. As part of our action plan, we have now finalised a technical specification for additional physical barriers at the locations you have identified on the ████████ floor and throughout the car park. A significant part of the car park already has barriers which have been installed at various times since the car park was originally built.” Source location 2024-0242 - Response from Leeds City Council
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4 Mar 2024 Vanessa FORD · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of wall mitigation and safety measures to impede railway access View source
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.
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AI-generated summary
Vanessa FORD · 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
On 23 September 2023, Vanessa Ford consumed a significant amount of alcohol during an acute mental health crisis, accessed the railway network and was struck by a train after dropping onto the tracks. The report raised concerns about frequent public access to the railway in the area, the effectiveness of safety measures on the wall, and street furniture making access easier and potentially undermining safety efforts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of wall mitigation and safety measures to impede railway access
Wider context from the report “(2) Evidence provided from CCTV footage and photographic evidence taken by the British Transport Police demonstrated that the particular piece of wall, which was used to access the railway network on 23 September 2023, was relatively low , despite an approximate drop onto the tracks below being 20 feet. The British Transport Police Post Incident Site Report sets out that the “Road over rail bridge has metal covers and hostile toppings on walls directly over the railway”; ████████
████████ This raises the concern that the mitigation/safety measures in place on the wall may not have been as effective as one might expect .
” Source location Vanessa FORD · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Martel Place wall following the report as part of continuous boundary asset management.
Verbatim wording from the response “I note the evidence referred to in your report regarding the nature of the wall at this location, specifically the wall along Martel Place referred to in the Post Incident Site Report. The wall has been reviewed again following receipt of your report as part of Network Rail’s continuous boundary asset management approach.” Source location Response from Network Rail
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify the Martel Place access gate to match adjacent fencing and remove the fence gap and climbing foothold.
Verbatim wording from the response “Although the boundary is assessed as compliant to Network Rail standards, we are working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken during early May 2024 to the access gate at Martel Place so that it matches the height of the adjacent palisade fencing and the gap underneath the fence and the climbing foothold will be removed. We are working with the Local Authority to consider options to add additional measures to the wall which may include the installation of Vanguard anti-climb rollers, planting Hawthorne or similar and installation of signage to warn people of the risks of the drop to the railway at the other side of the wall. It is anticipated that the selected option will be installed by early May 2024.” Source location Response from Network Rail
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Local Authority to explore additional wall measures addressing the incident’s specific access risks.
Verbatim wording from the response “Although the boundary is assessed as compliant to Network Rail standards, we are working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken during early May 2024 to the access gate at Martel Place so that it matches the height of the adjacent palisade fencing and the gap underneath the fence and the climbing foothold will be removed. We are working with the Local Authority to consider options to add additional measures to the wall which may include the installation of Vanguard anti-climb rollers, planting Hawthorne or similar and installation of signage to warn people of the risks of the drop to the railway at the other side of the wall. It is anticipated that the selected option will be installed by early May 2024.” Source location Response from Network Rail
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Network Rail is responsible for further measures addressing concerns about the Martel Place access gate and railway wall.
Verbatim wording from the response “11. The Council has also been in contact with Network Rail to coordinate actions and ensure clear ownership of responsibilities. The Council has received confirmation from Network Rail that further measures to address specific concerns around the access gate at Martel Place and the wall more generally are underway.” Source location Response from Hackney Council
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Includes barrier height, climbability, coverage, replacement and measurement failures where guarding is intended to prevent access to a dangerous drop or area.
