19 Jan 2024 John Thomas GRAY · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to protect mobility scooter users from falls at unbarriered promenade edges View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
East Suffolk Council
Complete new and updated risk assessments for Felixstowe Promenade, including consideration of risks to mobility scooter users.
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East Suffolk Council
Commission a full disability access audit of the promenade and surrounding area from a Centre for Accessible Environments-accredited assessor.
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East Suffolk Council
Monitor beach levels at promenade road entrances and ramps for 12 months to inform further safety measures.
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East Suffolk Council
Renew existing hazard line markings along the promenade.
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East Suffolk Council
Investigate the effectiveness and practicality of seasonal or more frequent releveling of beach sand and shingle.
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East Suffolk Council
Install signage at locations where beach levels fluctuate and create a fall risk.
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East Suffolk Council
Continue monitoring the structural integrity of existing barriers and maintain them.
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AI-generated summary
John Thomas GRAY · 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
John Thomas Gray died at Ipswich Hospital on 13 July 2022 after falling from the promenade at Felixstowe beach while asleep on his mobility scooter. He suffered multiple rib fractures leading to respiratory failure, and the inquest concluded that his death was accidental. The principal concern was that, where there was no barrier, existing signage and markings would not warn a person asleep on a mobility scooter about the risk of falling, potentially leading to future loss of life, particularly where the drop was unusually high.
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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 protect mobility scooter users from falls at unbarriered promenade edges
Wider context from the report “Evidence was also heard from a mobility scooter supplier and engineer, who explained that falling asleep on a mobility scooter was not uncommon, and happened more frequently than the general public might think. The supplier explained that this often led to accidents, leading to damage to the mobility scooters, which required repair.
I am therefore concerned that falls from the promenade onto the beach, in areas where there is no barrier, would occur again in similar circumstances , as the current signage and markings provide no warning to an individual asleep on their mobility scooter .
If this were to occur (as in this case) in an area where the height of drop from the edge of the promenade to the sand was greater than normally expected, I am concerned this would lead to future loss of life.
” Source location John Thomas GRAY · Prevention of Future Deaths 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 new and updated risk assessments for Felixstowe Promenade, including consideration of risks to mobility scooter users.
Verbatim wording from the response “In light of the incident, and prior to the coroner’s conclusion being published, East Suffolk Council reviewed its risk assessments to ensure risks relating to all users, including those with mobility scooters, were considered. The result of those risk assessments forms the basis of the response below.” Source location Response from East Suffolk 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 Commission a full disability access audit of the promenade and surrounding area from a Centre for Accessible Environments-accredited assessor.
Verbatim wording from the response “• Commission a full disability Access Audit of the promenade and its environs by a Centre for Accessible Environments (CAE) accredited assessor.” Source location Response from East Suffolk Council
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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 Monitor beach levels at promenade road entrances and ramps for 12 months to inform further safety measures.
Verbatim wording from the response “• Where required install guardrails (possibly removable) or other physical measures, such as corduroy paving, along full length of promenade edge or at particular higher risk points, such as entrance points/ramps off the road and locations where falls are onto rocks or hard surfaces (all subject to 12 months monitoring of beach levels and full disability Access Audit).” Source location Response from East Suffolk 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 Renew existing hazard line markings along the promenade.
Verbatim wording from the response “• Renew existing hazard line markings” Source location Response from East Suffolk Council
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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 Investigate the effectiveness and practicality of seasonal or more frequent releveling of beach sand and shingle.
Verbatim wording from the response “• Investigate the effectiveness and practicality of seasonal (or more frequent releveling of sand and shingle).” Source location Response from East Suffolk Council
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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 signage at locations where beach levels fluctuate and create a fall risk.
Verbatim wording from the response “• Install signage where there is a risk of fluctuating beach levels.” Source location Response from East Suffolk Council
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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 Continue monitoring the structural integrity of existing barriers and maintain them.
Verbatim wording from the response “• Continue to monitor the structural integrity of the existing barriers and to maintain them.” Source location Response from East Suffolk Council
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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 Preventing mobility scooter users from falling asleep is largely outside the Council’s control, limiting further responsive safety work.
Verbatim wording from the response “We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.” Source location Response from East Suffolk Council
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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 Mobility scooter leasing companies, medical professionals, families and individuals should identify and address risks of falling asleep while using mobility scooters.
Verbatim wording from the response “We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.” Source location Response from East Suffolk Council
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21 Apr 2023 Names not published · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Lack of a physical barrier preventing access to the hazardous bottom of the weir View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Environment Agency
Install a temporary downstream boom while reviewing options for the site, including possible weir removal.
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Environment Agency
Review all site options, including removal of the legacy weir.
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AI-generated summary
Names not published · 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
Two women were found in the River Great Ouse at Kempston Mill on 16 April 2023 after renting canoes, and both were pronounced dead at the scene. The report identifies concern that, although there was a barrier at the top of the weir, there was no similar barrier at the hazardous bottom where recirculating flow was present, particularly during high water levels.
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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 Lack of a physical barrier preventing access to the hazardous bottom of the weir
Wider context from the report “Although there is a physical barrier to prevent access to the top of the weir, there is no similar barrier to prevent access to the bottom which appears just as hazardous in view of the re-circulating flow (or towback), particularly during time of high water levels .
” Source location Names not published · Prevention of Future Deaths 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 temporary downstream boom while reviewing options for the site, including possible weir removal.
Verbatim wording from the response “As a result of the review for this site, whilst the facts of the incident are being established we are taking the following actions;” Source location Response from Enviroment Agency
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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 Review all site options, including removal of the legacy weir.
Verbatim wording from the response “1. Installation of a boom downstream of the weir on a temporary basis whilst a review of all the options for the site (including the removal of the weir) is undertaken. The weir serves no operational purpose to the delivery of the Environment Agency’s functions. It is a legacy asset, inherited from a predecessor body.” Source location Response from Enviroment Agency
Open published response
Concerns raised 1
Lack of railing protection alongside harbour and pier sheer drops View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cornwall Council Health and Safety Executive Porthleven Harbour & Dock Company
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James Francis PARSONS · 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
James Francis PARSONS died by drowning at Porthleven Harbour on 23 April 2022 after falling from the harbour wall into the water. The report identified safety concerns including sheer drops without railings, trip hazards, poor lighting, the absence of access ladders or refuge areas, and the pier being open to the public during the festival.
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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 Lack of railing protection alongside harbour and pier sheer drops
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water , and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” Source location James Francis PARSONS · Prevention of Future Deaths report
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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 Statutory health and safety enforcement for dock premises falls outside the council’s powers under the Health and Safety at Work etc. Act 1974.
Verbatim wording from the response “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.” Source location Response from Cornwall Council
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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 Health and Safety Executive is responsible for statutory enforcement concerning safety at the harbour’s dock premises.
Verbatim wording from the response “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.” Source location Response from Cornwall Council
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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 Existing railings, signage and lifebuoy aids are considered sufficient to address harbour safety risks.
Verbatim wording from the response “Over the years, the Harbour & Dock Company has given the utmost priority to safety aspects of the Harbour and continues to do so each year. We are satisfied with the measures we have in place which include railings, signage and lifebuoy aids. Being a popular holiday destination, Porthleven attracts thousands of visitors each year without incident which clearly demonstrates the Harbour is a safe environment.” Source location Response from Porthleven Harbour Dock Company
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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 HSE has no regulatory powers over harbour areas without work activity or risks increased by festivals and other public events.
Verbatim wording from the response “Porthleven Harbour is mainly concerned with recreational activities, including the mooring of privately owned pleasure boats. The Health and Safety at Work etc. Act 1974 only applies to Porthleven Harbour at locations where a work activity is taking place. That is paid work or where there is some form of remuneration, there is an employer/employee or self-employed person. Where the Act does not apply, HSE has no vires or regulatory powers.” Source location Response from Health and Safety Executive
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Concerns raised 1
Lack of physical measures preventing access over or around bridge railings and jumping to the carriageway View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Seth Curtis Palminder · 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
Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.
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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 Lack of physical measures preventing access over or around bridge railings and jumping to the carriageway
Wider context from the report “1. At the incident location ████████ there is little if anything by way of safety measures that would prevent anyone from being able to climb over, around or on top of the side railings of the bridge or to prevent them from jumping from the bridge to the carriageway . There is for example no enclosure of the walkway to prevent this .
” Source location Seth Curtis Palminder · Prevention of Future Deaths 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 Add the location to the South East Network Needs list for future funding prioritisation.
Verbatim wording from the response “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.” Source location Response from National Highways
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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 Apply for future funding for a study into preventing future suicide events at the location.
Verbatim wording from the response “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.” Source location Response from National Highways
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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 National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.
Verbatim wording from the response “The bridge at ████████ over the A3(████████) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3(████████) corridor, regardless of their primary usage. The ████████ bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used by pedestrians and cyclists.” Source location Response from Hampshire County Council
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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 existing 1.65-metre parapet complies with current standards, and enclosing the walkway is not considered appropriate because enclosed spaces can increase antisocial behaviour.
Verbatim wording from the response “The location is fitted with a parapet that met the required standards set out in
The Design Manual for Roads and Bridges (DMRB) at the time of construction in
1971 and remains compliant with current standards (DMRB CD 377
Requirements for road restraint systems). This parapet measures 1.65m high,
providing a protective barrier. Although historically some structures have been
enclosed for a number of reasons, including for suicide prevention or to prevent
items being thrown onto the carriageway below, this is not something that
highway authorities do now as the enclosed space often sees a rise in antisocial
behaviour and criminal activity.” Source location Response from National Highways
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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 Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.
Verbatim wording from the response “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.” Source location Response from National Highways
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23 Jun 2022 Mr Peter John Moorby · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure of the low wall to provide effective protection from the significant drop into the river View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Cumbria County Council
Work with residents to support measures reducing the risk of accidents from the wall.
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Cumbria County Council
Take appropriate enforcement action if agreement on reducing the risk is not reached.
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AI-generated summary
Mr Peter John Moorby · 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
Peter John Moorby fell approximately 8–10 feet over a low wall into a beck in an unlit area and sustained severe head injuries. He died in hospital on 5 September 2021. The concern was that the low wall offered little protection from the drop and that the area was unlit at night, creating a risk of future deaths.
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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 the low wall to provide effective protection from the significant drop into the river
Wider context from the report “I am concerned about the risk of future deaths posed by the low wall. The wall is less than knee height and offers no real protection from the significant drop of 8-10 feet into the River Eea which has a rock-strewn riverbed. The area is also unlit at night.
” Source location Mr Peter John Moorby · 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 Work with residents to support measures reducing the risk of accidents from the wall.
Verbatim wording from the response “The Council commits to fulfil its duty as a Street Authority under the Highways Act and will work with the residents to support them to take action to reduce the risk and likelihood of future accidents from the wall.” Source location Response from Cumbria County 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 Take appropriate enforcement action if agreement on reducing the risk is not reached.
Verbatim wording from the response “The Council aims to meet with residents not later than the end of November 2022 to try to reach agreement on a way forward not later than the end of January 2023. Failing that, the Council will take the appropriate enforcement action, with a view to completion of the necessary works as soon as possible thereafter.” Source location Response from Cumbria County Council
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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 Primary responsibility for action regarding the wall lies with property owners fronting the private street.
Verbatim wording from the response “The Council has considered the Regulation 28 report to prevent future deaths and notes that as the wall is on a private street, that primary responsibility for action lies with the owners of the properties fronting the street.” Source location Response from Cumbria County Council
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22 Jun 2022 Connor Peter Marron · Prevention of Future Deaths report North London
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Concerns raised 1
Inadequate fencing preventing ingress to the railway track View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Connor Peter Marron · 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
Connor Peter Marron was struck and fatally injured by a train on 2 January 2022 near Hornsey Railway Station after leaving a public house to return to Alexander Palace. Concerns included inadequate lighting and signage near the stream and railway fence, and a fence that was not adequate to prevent access to the railway track.
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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 fencing preventing ingress to the railway track
Wider context from the report “3. The fence separating the venue grounds from the railway track was not adequate to prevent ingress to the railway track .
” Source location Connor Peter Marron · 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 Repair damage to the Downside access gate and minor fencing defects.
Verbatim wording from the response “In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.” 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 Replace the chain-link fencing section with palisade fencing through the Route’s work bank.
Verbatim wording from the response “• replacing the relevant section of chain link fencing and continuing with palisade fencing. Whilst, as mentioned previously, the route to the incident scene has been deemed inconclusive, we note that the fencing in closest proximity to the incident scene is, in fact, palisade fencing, rather than chain link fencing (the fencing in this particular area, which separates the venue grounds from the railway track, is currently of a mixed palisade and chain link design). Class I boundary measures, which include palisade fencing, are installed to provide a security measure where the risk of unauthorised access is probable and these boundary measures are designed with anti-tamper and anti-climb components within the installation. The chain link section of fencing is approximately ¼ mile down the track, on the opposite side of the tracks and across approximately 6 miles of track.” 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 Invest in physical measures to prevent unauthorised railway access, including platform-end barriers, mid-platform station fences and lineside fencing.
Verbatim wording from the response “I note that the conclusion of this inquest was an ‘open’ verdict. However, I thought you may be interested in some of the other work we do as we are committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. An example of this is the work being carried out on the Peterborough to Kings Cross line of route, where this section of track is located, which is one of three Focus Areas where Network Rail is working closely with the British Transport Police, Samaritans and Rail Industry partners to prevent suicide. Network Rail has also invested significantly in preventing unauthorised access in this line- of-route through physical mitigations, such as platform end barriers and mid-platform fences at stations and lineside fencing outside.” 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 The stream lighting and railway-fence adequacy matters concern assets APPCT does not own or operate and therefore do not require action by APPCT.
Verbatim wording from the response “railway assets owned by Network Rail. To access the railway boundary fence, an individual must first leave the park onto public streets and cross the New River; two locations owned by third parties.” Source location Response from Alexandra Palace
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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 Lighting on venue grounds is Alexandra Palace’s responsibility, while railway fencing is Network Rail’s responsibility.
Verbatim wording from the response “I will address point number 1, as the other issues appear to relate to the responsibilities of Alexandra Palace and Network Rail respectively. Point 2 relates to lighting on the venue grounds, which is for Alexandra Palace, and fencing separating the venue from the railway track would appear to be the responsibility of Network Rail.” Source location Response from Thames Water
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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 The route by which access to the railway occurred is inconclusive, and fencing nearest the incident was palisade rather than chain link.
Verbatim wording from the response “In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.” 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 Quarterly inspections and remediation under the boundary fencing standard are considered sufficient for fence-line maintenance.
Verbatim wording from the response “• ensuring that fence line inspections comply with the National Safety Briefing in relation to Boundary Fencing Inspection Standard NR/L2/OTK/5100 Module 01 (1st April 2019) tactile / non-tactile inspections (“the Standard”). Network Rail takes a pro-active approach to asset maintenance and renewal, with inspections complying with the Standard and remediation works carried out following such inspections. Where upgrading of an asset is identified as being required, a fencing proposal is prepared by the Off-Track team and ranked in terms of priority, with those with the highest scores (indicating that they are the highest priority) given precedence. Each route within an area is allocated a fund of monies to be used for maintenance and repair works, with monies focused on delivering the highest priority works identified i.e., those with the highest scores.” Source location Response from Network Rail
Open published response
Concerns raised 1
Failure to prevent pedestrians climbing over the bridge parapet View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Durham County Council
Complete high-risk-location review, feasibility study and options appraisal to identify a preferred suicide-prevention measure for Newton Cap Viaduct.
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Durham County Council
Undertake detailed design and approval assessments for a potential additional parapet fence, including structural, traffic, heritage and planning considerations.
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Durham County Council
Source an external consultant specialising in designing out suicide to progress viaduct prevention measures.
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AI-generated summary
Joseph William DENT · 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
Joseph William DENT was seen parking a car near Newton Cap Viaduct in the early hours of 20 June 2021, and his body was found near the base of the bridge shortly after 08:00. The investigation found that he died from multiple injuries after falling from the bridge, with an open conclusion because it was unclear how he came to fall. Concerns included pedestrian access to the bridge parapet and the area below, the lack of effective climbing prevention, the absence of monitored CCTV and lighting or other detection measures, and the bridge’s reported association with suicide by jumping.
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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 pedestrians climbing over the bridge parapet
Wider context from the report “All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge ;
(2) the bridge is frequently discussed on social media as suitable location for suicide by jumping;
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall
Detective Sergeant ████████ gave evidence that:
(a) there is pedestrian access to either side of the bridge;
(b) the bridge lacks effective measures to prevent persons climbing over the parapet ;
(c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media); and that
(d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge.
Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians.
My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide.
” Source location Joseph William DENT · 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 Complete high-risk-location review, feasibility study and options appraisal to identify a preferred suicide-prevention measure for Newton Cap Viaduct.
Verbatim wording from the response “In 2018, the Council’s Public Health department produced a High Frequency Location Report for Suicide Prevention, which reviewed a number of high-risk geographical locations across County Durham, including Newton Cap Viaduct. This review initiated a Feasibility Study (2019) which was undertaken to assess options for any suicide prevention measures specifically for Newton Cap Viaduct. After the unprecedented public health protection pressures on the Council during the Covid-19 pandemic subsided, a further options appraisal was developed, and a preferred option (Option 1) was identified. On 15th September 2021, the Council’s Corporate Management Team (CMT) requested further detailed work be undertaken on Option 1 to consider the possibility of mounting an additional fence to the face of the concrete parapet upstand of the structure on both east and west elevations.” Source location 2021-0297-Response-from-Durham-County-Council_Published
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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 Undertake detailed design and approval assessments for a potential additional parapet fence, including structural, traffic, heritage and planning considerations.
Verbatim wording from the response “In 2018, the Council’s Public Health department produced a High Frequency Location Report for Suicide Prevention, which reviewed a number of high-risk geographical locations across County Durham, including Newton Cap Viaduct. This review initiated a Feasibility Study (2019) which was undertaken to assess options for any suicide prevention measures specifically for Newton Cap Viaduct. After the unprecedented public health protection pressures on the Council during the Covid-19 pandemic subsided, a further options appraisal was developed, and a preferred option (Option 1) was identified. On 15th September 2021, the Council’s Corporate Management Team (CMT) requested further detailed work be undertaken on Option 1 to consider the possibility of mounting an additional fence to the face of the concrete parapet upstand of the structure on both east and west elevations.” Source location 2021-0297-Response-from-Durham-County-Council_Published
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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 Source an external consultant specialising in designing out suicide to progress viaduct prevention measures.
Verbatim wording from the response “This more detailed work also includes the requirement for assessments on the impact for road traffic accidents if a barrier was to be installed, Listed Building Consent, Planning Consent and a full design and approval process. The council is currently sourcing an external consultant versed in the speciality of ‘designing out suicide’ to progress next steps. Any changes made to the viaduct will depend on the ability of the structure’s foundations to host any suggested measures whilst also accommodating wind speeds and the needs of local residents, road users, cyclists and conservation. A provisional date for the completion of this assessment work still requires formal confirmation from the provider.” Source location 2021-0297-Response-from-Durham-County-Council_Published
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Concerns raised 1
Incomplete and gapped wire fencing along the viaduct parapet wall View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Clive OXLEY · 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
Clive OXLEY entered the track at Durham railway station, climbed the viaduct parapet, and jumped onto North Road below. Concerns included whether the pedestrian barrier adequately prevented access to the track and whether gaps and limited coverage in the wire fence enabled access to the parapet; two similar incidents were also noted.
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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 Incomplete and gapped wire fencing along the viaduct parapet wall
Wider context from the report “2) The impression from officers from the British Transport Police and Durham CID who gave evidence is that the wire fence that extends the height of the viaduct parapet wall runs along only a short length of the wall , and that there are in any event gaps between the sections of that fence , the deceased gaining access to the parapet wall through one such gap.
” Source location Clive OXLEY · 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 Provide platform-end gates and fencing at higher-risk locations to restrict unauthorised access to the railway.
Verbatim wording from the response “In order to make suicide and trespass as difficult as possible, platform end gates and fencing is provided, and prioritised at locations deemed higher risk to prevent access to the line wherever possible. With specific regards to Durham, this is supported by signage promoting services offered by the Samaritans and the warning system that is in place at the Station. In addition, LNER have trained a significant number of staff in suicide risk who are given guidance and training in dealing with vulnerable people when they are seen on the rail network.” Source location 2020-0301-Response-from-LNER-Redacted
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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 Contact Network Rail to seek a joint site visit assuring that the fencing meets rail-industry standards.
Verbatim wording from the response “LNER have made contact with Network Rail with a view to arranging a joint site visit in order to seek assurance that the fencing meets the requirements of the rail industry standards.” Source location 2020-0301-Response-from-LNER-Redacted
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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 Liaise with stakeholders and planning authorities to consider installing wire-mesh fencing along the viaduct parapet.
Verbatim wording from the response “Significant parapet fencing has previously been trialled at this location. However, the viaduct has Grade II listed status, which introduces constraints in this respect. Our mandatory fencing standard was therefore applied. Following receipt of your report we are liaising with relevant stakeholders and appropriate planning authorities to consider whether additional measures can be taken over and above what is required in the fencing standard. Specifically, we are considering whether a wire mesh fence can be installed along the parapet to restrict individuals from climbing over the existing structure. This is something that we have done at other Grade II listed structures. In the meantime, the fencing at the viaduct is compliant with and will continue to be maintained as required by our mandatory fencing standard.” Source location 2020-0301-Response-from-Network-Rail-Redacted
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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 generally responsible for platform end and boundary fencing beyond LNER’s day-to-day station management.
Verbatim wording from the response “LNER work collaboratively with Network Rail to reduce the number of trespass and fatality incidents along the LNER line of route, though in practical terms, LNER operate Durham Station under a long-term lease and are generally responsible for the day to day management of the Station. Platform end fencing and general boundary fencing in place to prevent unauthorised access to the track and other infrastructure is generally the responsibility of Network Rail.” Source location 2020-0301-Response-from-LNER-Redacted
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1 Dec 2020 Ibrahima YAHAIA · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to prevent pedestrian access to Busway lanes View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ibrahima YAHAIA · 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
Ibrahima YAHAIA, who had memory issues and was a French non-English-speaking national, was fatally struck by a bus while walking along the designated busway in Luton on 15 January 2020. The concerns included unrestricted pedestrian access to the busway, gaps in fencing and inadequate signage, previous serious incidents, alleged design flaws, and no evidence of steps to prevent further injuries or deaths.
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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 pedestrian access to Busway lanes
Wider context from the report “(1) There is a pedestrian footway which runs parallel to the Busway in places and pedestrians have access to the Busway at bus stops. Pedestrians may cross the Busway at the bus stops and there is no physical prevention for pedestrians to enter the Busway lanes . There is no signage on the Busway, itself stating pedestrians should not enter and only a small sign on a post by the footpath which states pedestrians should not trespass on the Busway. Although the footpaths which run parallel to the Busway are separated by fences, there are a number of places where pedestrians may freely enter the Busway . Hatters Way, Luton has many gaps in the fence, with no gate, giving pedestrians free access to roam in and out of the Busway lanes . There are no signs of bus stops near these gaps in the fences and, at the Bury Park end of Hatters Way, there is no fencing which again means pedestrians are free to enter the Busway lanes . Unlike train tracks, where the only way to get access is via a station, the Busway is easily accessed, yet it is just as dangerous;
” Source location Ibrahima YAHAIA · Prevention of Future Deaths report
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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 Entire-length fencing cannot be installed because it would be prohibitively expensive and is not considered necessary for busway infrastructure.
Verbatim wording from the response “At no stage has LBC or CBC been advised that the Busway should be fenced along its entire length and indeed to do so would be prohibitively expensive. I understand that no busways are fenced in the same way as a railway and the two should not be seen as comparable.” Source location 2020-0262-Response-from-Luton-Council-Redacted
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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 Unauthorised access cannot be prevented along the Busway’s full 8.3-mile length.
Verbatim wording from the response “I feel that I must nonetheless point out that it is impossible to prevent unauthorised access to the Busway along its 8.3 mile length of which 4.6 miles is guided.” Source location 2020-0262-Response-from-Luton-Council-Redacted
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30 Mar 2020 JORDAN MICHAEL AIRA · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of physical boundaries preventing public access to railway tracks View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
JORDAN MICHAEL AIRA · 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
Jordan Michael Aira was electrocuted after walking onto the railway lines at Ashford Station in the early hours of 23 March 2019. The concerns included inadequate physical barriers, the location of the emergency telephone, warning signs that did not explicitly warn of immediate death from touching the live rail, and no national curriculum requirement to teach pupils about the risk posed by live rails.
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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 Lack of physical boundaries preventing public access to railway tracks
Wider context from the report “1. There were no physical boundaries at the end of the platform preventing members of the public accessing the railway tracks .
” Source location JORDAN MICHAEL AIRA · 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 Deploy Rail Safety Accredited Security Officers to patrol for trespass and antisocial behaviour and target hotspot locations with partner agencies.
Verbatim wording from the response “Locally to SWR, we have Rail Safety Accredited Security Officers (Rail Community Officers) whose core activities include the following:” Source location 2020-0082-Response-from-South-Western-Railway_Redacted
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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 Add extra platform markings and barriers at Ashford station to further deter trespass.
Verbatim wording from the response “Ashford was not therefore a priority station for additional barriers. However, as was explained at the Inquest, work to improve that station is planned and will now include extra platform markings and barriers to further deter trespass.” Source location 2020-0082-Response-from-Network-Rail_Redacted
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.