Recurring concern

Inadequate safety controls for access ramps

Pin Get email alerts Request correction

First reported 24 Dec 2015•Latest report 27 Mar 2026

Definition

What this concern includes

Includes failures of controls specifically dedicated to making access ramps safe for users, including ramp stability or fixing, surface security, gradient, handrails, edge protection, lighting and formal risk assessment or remedial safety measures.

Not included

  • Excludes general falls, mobility or physical-access concerns where an access ramp is not the material unsafe object.
  • Excludes ordinary building maintenance or accessibility deficiencies that do not create a safety risk during ramp use.
  • Excludes stairs, balconies, dangerous drops and other access features unless the assertion explicitly concerns a comparable access-ramp safety condition.
  • Excludes generic risk-assessment, staffing or documentation failures unless they directly concern the safety of an access ramp.
Reports
2

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
4

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.

James Paget University Hospital1
Norfolk and Norwich University Hospital1
Norfolk and Suffolk NHS Foundation Trust1
Sai Skn Limited1
The Queen Elizabeth Hospital, King's Lynn1

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. Manchester South

    AI-generated summary

    Edith Millington · 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

    Edith Millington, aged 90, fell while attempting to enter a convenience store using a mobility scooter and walking stick, striking her head. She died at Salford Royal Hospital on 09.09.25, with the medical cause of death recorded as traumatic intracranial haemorrhage. The concern was that the store’s ramp was unsafe because it was unsecured, its rubber mat was not fixed, accessible handrails were absent, and the ramp was too short and steep, creating a risk of a similar fatal fall.

    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

    Access ramp that is too short and therefore too steep

    Wider context from the report

    “The evidence, today, of your store supervisor ████████ was that the ramp remains exactly as it was on the day of EM’s fatal accident. It is my opinion that the structure/design of the ramp makes it unsafe. In particular that the ramp itself is not fixed or secured to the ground (not even semi-fixed so that it can be removed at the end of the day), that the rubber mat is not fixed and can easily move (as seen), there are no external easily accessible handrails, and the ramp is too short making the slope steeper. The issue of concern is that unless action is taken to render access to the store by way of a safer design of ramp then there is a high risk of a customer, particularly a customer with mobility issues, suffering a similar and fatal fall as EM. ”

    Source location

    Edith Millington · 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 secure the rubber ramp mat against movement

    Wider context from the report

    “The evidence, today, of your store supervisor ████████ was that the ramp remains exactly as it was on the day of EM’s fatal accident. It is my opinion that the structure/design of the ramp makes it unsafe. In particular that the ramp itself is not fixed or secured to the ground (not even semi-fixed so that it can be removed at the end of the day), that the rubber mat is not fixed and can easily move (as seen), there are no external easily accessible handrails, and the ramp is too short making the slope steeper. The issue of concern is that unless action is taken to render access to the store by way of a safer design of ramp then there is a high risk of a customer, particularly a customer with mobility issues, suffering a similar and fatal fall as EM. ”

    Source location

    Edith Millington · 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

    Absence of external, easily accessible handrails on the access ramp

    Wider context from the report

    “The evidence, today, of your store supervisor ████████ was that the ramp remains exactly as it was on the day of EM’s fatal accident. It is my opinion that the structure/design of the ramp makes it unsafe. In particular that the ramp itself is not fixed or secured to the ground (not even semi-fixed so that it can be removed at the end of the day), that the rubber mat is not fixed and can easily move (as seen), there are no external easily accessible handrails, and the ramp is too short making the slope steeper. The issue of concern is that unless action is taken to render access to the store by way of a safer design of ramp then there is a high risk of a customer, particularly a customer with mobility issues, suffering a similar and fatal fall as EM. ”

    Source location

    Edith Millington · 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 fix or secure the access ramp to the ground

    Wider context from the report

    “The evidence, today, of your store supervisor ████████ was that the ramp remains exactly as it was on the day of EM’s fatal accident. It is my opinion that the structure/design of the ramp makes it unsafe. In particular that the ramp itself is not fixed or secured to the ground (not even semi-fixed so that it can be removed at the end of the day), that the rubber mat is not fixed and can easily move (as seen), there are no external easily accessible handrails, and the ramp is too short making the slope steeper. The issue of concern is that unless action is taken to render access to the store by way of a safer design of ramp then there is a high risk of a customer, particularly a customer with mobility issues, suffering a similar and fatal fall as EM. ”

    Source location

    Edith Millington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remove the metal access ramp and replace the former ramp arrangement with a small, stable entrance step.

    Verbatim wording from the response

    “Following a full review of the incident and the issues identified, with further consultation and input from ████████ from Trafford Council we have taken immediate corrective action in respect of the entrance to our premises.”

    Source location

    Response from Sai SKN Ltd
    Page 1 · response
    Published 7 April 2026

    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 fixed grab rails on both sides of the entrance to improve customer support and stability.

    Verbatim wording from the response

    “• Additional fixed grab rails have been installed on both sides of the entrance to provide improved support and stability for customers entering and exiting the store.”

    Source location

    Response from Sai SKN Ltd
    Page 1 · response
    Published 7 April 2026

    Open published response

  2. Norfolk

    AI-generated summary

    CHRISTOPHER JONATHAN HIGGINS · 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

    Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

    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 risk assess and make safe the physical environment before patient access

    Wider context from the report

    “(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette. It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death. Other ways of making the area safe are still under consideration. ”

    Source location

    CHRISTOPHER JONATHAN HIGGINS · 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

    Add additional height bars to the disabled-access ramp railing to reduce the likelihood of people jumping over it.

    Verbatim wording from the response

    “Following the incident the Trust reviewed the railing that sits with the disabled access ramp, adding additional height bars to reduce the likelihood that an individual could, from a standing position, jump over the top of them.”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 24 December 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

    Fully enclose the ramp to remove the possibility of an individual jumping from its top area.

    Verbatim wording from the response

    “Following the inquest the Trust has revisited the assessment of this area. Whilst there are mitigations in place such as the heightened rail and access to the area by patients is made with supervision, the Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016 and removes the possibility of an individual jumping from the top of the ramp area.”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 24 December 2015

    Open published response
Back to top

Data last updated 7 September 2026