Recurring concern

Inadequate physical barriers preventing access to dangerous drops or areas

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First reported 21 Nov 2013•Latest report 6 Mar 2026

Definition

What this concern includes

Includes barrier height, climbability, coverage, replacement and measurement failures where guarding is intended to prevent access to a dangerous drop or area.

Not included

  • Clinical bed or chair fall-prevention controls
  • Vehicle collision barriers
  • Security controls with no physical-injury hazard
Reports
46

Distinct published reports

Individual concerns
57

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
90

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Network Rail14
Cornwall Council3
Durham County Council3
National Highways3
Canal & River Trust2
Hammerson PLC2
Isle of Wight Council2
Recipient name withheld2
The National Trust For Places Of Historic Interest Or Natural Beauty2
Alexandra Park and Palace Charitable Trust1
Arriva Rail North Limited1
Bedford Borough Council1
British Transport Police1
Calderdale Borough Council1
Chesterfield Borough Council1

Concerns and responses across reports

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

  1. West Sussex

    AI-generated summary

    Alasdair Neal Penny · 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

    Alasdair Neal Penny, a 23-year-old man, jumped from a road bridge onto the road below on 4 May 2014 and died from multiple injuries. The bridge had previously been the site of a suicide, and the concern was whether additional protection could make it more difficult to use the bridge as a suicide site and minimise recurrence.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of bridge railings to prevent easy mounting

    Wider context from the report

    “This Bridge has been the site of 2 suicides in 2011 and 2014; I am unaware if there have been any other successful suicides at this location before then, but if so, not in the very recent past. In each of the 2 cases the deceased jumped from the bridge on to the road below, a distance of 10-11 metres. The 2 footpaths that bound the carriageway each have a metal railing and the height of the railing is such that they can be quite easily mounted. There is a series of discrete notices on the mesh infill to the railings, giving details, I understand, of the Samaritans. I cannot, and do not, offer a solution I certainly recognise that merely raising the level of the railing may not prevent the determined person to climb up and jump. But it might well stop the spontaneous jumper. I understand that I do not know whether it is possible/feasible to provide extra/or some other form of protection in order to make it more difficult for the bridge to be used as a suicide site. However, I do believe that the whole situation should be reconsidered in case something can be reasonably implemented to minimise the possibility of a recurrence. ”

    Source location

    Alasdair Neal Penny · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Investigate the technical feasibility of increasing the College Lane Bridge parapet height to deter future jumps.

    Verbatim wording from the response

    “While we would caution that it is unlikely that any engineering solution would be 100% effective we will be investigating whether it is technically feasible to increase the height of the current parapet to deter as far as practicable similar events occurring in the future. If an appropriate solution can be determined we intend to undertake the alterations within this financial year, subject to any design and programming constraints. If an appropriate technical solution cannot be realised I will write to you again explaining the reasons why.”

    Source location

    2015-0106-Response-by-West-Sussex-County-Council
    Page 2 · response
    Published 17 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Participate in the planned update meeting on potential bridge alterations.

    Verbatim wording from the response

    “The potential alterations to the bridge are being managed by WSCC and an update meeting is planned between Peter Lawrence (WSCC), Julie Holden (EGTC) and PS Graeme Prentice (Sussex Police) on the 20th May 2015.”

    Source location

    2015-0106-Response-by-Sussex-Police
    Page 2 · response
    Published 17 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    WSCC is responsible for managing decisions and delivery concerning potential alterations to the bridge.

    Verbatim wording from the response

    “The raising of the parapets, which was the partners preferred recommendation, was referred to WSCC and was discussed at the County Local Committee meeting in late 2014. WSCC reported that the vegetation could not be cut back and a report was being prepared as to the reasons why.”

    Source location

    2015-0106-Response-by-Sussex-Police
    Page 2 · response
    Published 17 March 2015

    Open published response
  2. Isle of Wight

    AI-generated summary

    John Ramsay Darling · 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 Ramsay Darling, aged 84, died after his wheelchair rolled over the unguarded edge of a café platform and he sustained a head injury. The principal concern was that the platform had an approximately one-metre drop without a physical barrier, creating risks for wheelchair users, children, buggies and other patrons, particularly because of the platform’s incline and busy conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to require physical safeguarding of the platform edge during planning

    Wider context from the report

    “6. It should be mentioned that the Isle of Wight Council Planning Department had not requested that any physical measures in the form of a barrier or balustrade be implemented to protect patrons from falling off the edge of the platform, notwithstanding that there had been three objections (later withdrawn) from members of the public at the Planning and Licensing Consultation stage. Clearly, with the Café open for less than 2 months before this fatality occurred the position adopted by the Isle of Wight Planning Department is untenable and needs to be reviewed. ”

    Source location

    John Ramsay Darling · Prevention of Future Deaths report
    Page 3 · concerns

    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 physical protection at the platform edge

    Wider context from the report

    “1. The “Off The Rails Café” has a platform which has an unguarded edge with a drop of approximately a metre onto the area where the railway track used to be. Whilst there is a painted warning on the ground at the point of the edge, I am concerned that this is an accident which is almost inevitably going to reoccur as there is nothing to stop anyone falling over the edge. 2. A painted warning sign on the platform edge warning of the danger is of no use to those who are in baby buggies, or to toddlers or small children who may easily fall off the edge, or to someone who accidentally walks back over the edge. 3. I am concerned that at busy times, it would be all too easy for someone to lose their footing and stumble off the edge of the platform. ”

    Source location

    John Ramsay Darling · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. Peterborough

    AI-generated summary

    LYNN MARGARET GRAHAM GORMLEY · 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

    At approximately 12:20 on 23 December 2013, Lynn Margaret Graham Gormley jumped from level 11 of Queensgate Car Park and died of multiple injuries. The report raises concerns that the car park design did not provide effective barriers to jumping, that falls also posed a risk to pedestrians, and that there had been a number of suicides from the car parks since 2006.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of Queensgate and other City Centre car park barriers to prevent jumping

    Wider context from the report

    “(1) There have been a number of suicides from 2006 onwards, where individuals have taken their own lives by jumping from the Queensgate Car Parks. The current design of the car park is not effective in preventing jumps and the recent refurbishment of the car parks did not lead to the erection of barriers/increasing the height of the walls. Of note is the paper (attached) by ████████ and others (BMC Public Health 2013, 13:214) which concluded that notwithstanding certain limitations of the review undertaken, reducing access to means through the installation of barriers can be effective in averting suicides at hotspots and does not lead to substitution effects. (2) The car park at Peterborough City Hospital which was opened in 2010 and is therefore of modern design, was constructed in such a way as to provide a significant obstacle to jumping as the wall on the top floor is approximately 3 meters high. By contrast, the walls at the upper floors of the Queensgate Car Parks and other City Centre car parks, are at a low level and do not operate as an effective barrier to jumping. (3) Falls from the car parks have been into areas where the public use pavements and there is clearly a risk of death to pedestrians also. (4) There is evidence in the medical notes and records of some of those who have taken their own lives, that car parks are seen as a means of effecting death by jumping. ”

    Source location

    LYNN MARGARET GRAHAM GORMLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission and complete a feasibility assessment of infilling or over-cladding car-park openings, including options, costs and prioritisation.

    Verbatim wording from the response

    “IREEF – Queensgate Peterborough PropCo S.à r.l. (“IREEF”) acquired the centre in January 2014 and since acquisition have identified that there had been a recent increase in the number of attempted suicides and suicides at the Queensgate Centre in Peterborough. We therefore instructed Workman LLP, the largest independent commercial property management and building consultancy firm in the UK, on 20 June 2014, to review and consider physical alterations to infill/over-clad openings to the car park floors. Workman was instructed to progress with a full feasibility study to consider options and costs for a number of infill and over-clad solutions. The feasibility team comprises the following:”

    Source location

    2014-0356-Response-by-Invesco
    Page 2 · response
    Published 30 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Finalise the detailed design for the preferred web-net infill solution.

    Verbatim wording from the response

    “Following that site visit, an updated / final presentation was held on 12 September 2014, where further detail was provided by Beyond to the Landlord on the web-net system. At that meeting it was agreed in principal that the preferred option was the infill option of the web-net system.”

    Source location

    2014-0356-Response-by-Invesco
    Page 3 · response
    Published 30 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Install a sample web-net system on site to assess the preferred solution.

    Verbatim wording from the response

    “Further to the meeting held on 18 July 2014, it was agreed that given a web-net system was the preferred solution, a small number of samples of the system should be installed. In conjunction with this further technical literature should be obtained on the product and investigations undertaken into alternative manufacturers with similar systems. Arrangements were also made for representatives of the feasibility team to conduct a site visit to a location where a web-net system was in use in order to assess the suitability of the option and that visit took place on 20 August 2014.”

    Source location

    2014-0356-Response-by-Invesco
    Page 3 · response
    Published 30 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Invite tenders for the proposed car-park infilling and over-cladding works.

    Verbatim wording from the response

    “• Project tender – we will proceed with inviting tenders for the works”

    Source location

    2014-0356-Response-by-Invesco
    Page 3 · response
    Published 30 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commence construction of the car-park infilling and over-cladding works.

    Verbatim wording from the response

    “• Construction commences”

    Source location

    2014-0356-Response-by-Invesco
    Page 3 · response
    Published 30 July 2014

    Open published response
  4. Bedfordshire and Luton

    AI-generated summary

    Ernest Charles 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

    Ernest Charles Harper fell from the tailgate lift of a small minibus while returning from the Goldington Day Care Centre, sustaining injuries including a right subdural and subarachnoid haemorrhage. Concerns were raised that a passenger could fall between the safety barrier and the back of the vehicle, and that mobility information used for risk assessment depended on voluntary information rather than a formal assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Fall hazard between the safety barrier and the back of the vehicle

    Wider context from the report

    “(1) That it was possible to fall between the safety barrier and the back of the vehicle ”

    Source location

    Ernest Charles Harper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Retrofit safety devices to the doors of all Ford Transit vehicles to block gaps between the vehicle rear and handrail.

    Verbatim wording from the response

    “Devices have been retro-fitted to the doors on all Ford Transit vehicles, the type of vehicle the accident occurred on. This blocks the gaps between the back of the vehicle and the handrail.”

    Source location

    2014-0223-Response-by-Bedford-Borough-Council
    Page 1 · response
    Published 9 May 2014

    Open published response
  5. County Durham and Darlington

    AI-generated summary

    Sopeluwa Babatunde Peters · 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

    Sopeluwa Babatunde Peters died by drowning in the River Wear on 30 October 2013, after likely falling into the river while descending steep steps in Drury Lane, Durham City, while under the influence of alcohol. Concerns included poor illumination, the absence of a handrail, the steepness of the steps, and a low riverside wall that provided limited safety protection.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Low riverside wall providing inadequate safety barrier

    Wider context from the report

    “(1) The steps are steep, poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier. ”

    Source location

    Sopeluwa Babatunde Peters · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Install a timber barrier beside the wall opposite Drury Lane’s exit to reduce the risk of falls into the river.

    Verbatim wording from the response

    “I can confirm that whilst no action is being proposed in respect of the above mentioned matters, the Council will be installing a timber barrier in the riverside footpath, adjacent to the wall opposite the exit from Drury Lane. The installation of a barrier should reduce any potential risk of someone falling or running down the steps and going over the wall into the river at this location. This barrier will be placed within the footpath itself, as the path is within the control of the County Council. It is anticipated that this barrier will be installed within the next two weeks.”

    Source location

    2014-0206-Response-by-Durham-County-Council
    Page 2 · response
    Published 8 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake a riverbank risk assessment with police representatives to identify locations associated with evening and night-time activity.

    Verbatim wording from the response

    “The County Council will also be undertaking a risk assessment along sections of the river bank. This assessment will include representatives from the police who will identify locations, from their local knowledge of where there is a volume of evening and night time activity. If further risks are identified these will be assessed and action will be taken by the County Council to minimise such risks as is considered appropriate.”

    Source location

    2014-0206-Response-by-Durham-County-Council
    Page 2 · response
    Published 8 May 2014

    Open published response
  6. Manchester North

    AI-generated summary

    Lisa Jane CLAYTON · 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

    Lisa Jane Clayton had severe clinical depression and a history of self-harm attempts. On 27 June 2012, she went missing from home and was found at the foot of The Spindles car park after being seen on the wall surrounding its seventh floor. The principal concerns were that the wall and rails provided insufficient prevention of access, CCTV monitoring and security-control-room staffing were inadequate, and previous concerns about suicide attempts at the location had not led to sufficient action.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of the wall rails to prevent climbing onto the car park wall

    Wider context from the report

    “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself. 2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1. 3) The wall/rails are an insufficient deterrent/preventative measure. 4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor. 5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room. 6) There have been previous acts and attempts by others to take their own life, at the same location. Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles. In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same. Despite this, little direct action has (or appears to have) been taken. ”

    Source location

    Lisa Jane CLAYTON · Prevention of Future Deaths report
    Page 2 · concerns

    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 the low metal barrier from providing a foothold for climbing onto the car park wall

    Wider context from the report

    “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself. 2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1. 3) The wall/rails are an insufficient deterrent/preventative measure. 4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor. 5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room. 6) There have been previous acts and attempts by others to take their own life, at the same location. Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles. In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same. Despite this, little direct action has (or appears to have) been taken. ”

    Source location

    Lisa Jane CLAYTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026