Recurring concern

Inadequate handrail safety on steps and access ramps

First to latest report 8 May 2014 — 27 Mar 2026

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
8

What this concern includes

Includes deficiencies in the design, provision, accessibility, dimensions, positioning or operational protection of handrails serving steps or access ramps, including failures to guide staff or stewards so that handrails remain unobstructed.

What is not included
  • Excludes general falls, stair-surface, lighting or access hazards where handrail safety is not the identified unsafe condition.
  • Excludes handrails on bridges, balconies or other elevated edges where the primary function is fall prevention rather than support during use of steps or access ramps.
  • Excludes generic staffing, stewarding, maintenance or documentation failures unless they directly impair the availability, accessibility or safe use of a handrail.
  • Excludes handrail deficiencies in clinical equipment, vehicles or non-access structures.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  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

    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 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. Cornwall and Isles of Scilly

    AI-generated summary

    Ann Campbell · 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

    Ann Campbell was found deceased at the foot of steep concrete steps leading to her basement flat on 15 November 2024, having sustained a skull fracture likely caused by falling down the steps; alcohol intoxication was also recorded. The principal concern was that the steps were difficult to access because the handrail was too low to allow someone descending to steady themselves.

    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 handrail to provide adequate height for people descending steps

    Wider context from the report

    “1) Access to the steps is difficult. In particular, someone who is about to descend the steps is not able to steady themselves by grasping a handrail because it is too low/does not extend up higher than is currently the case. ”

    Source location

    Ann Campbell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. North West Kent

    AI-generated summary

    Richard HEDGES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide a handrail with sufficient end support on the external staircase

    Wider context from the report

    “(2)The handrail for use with the steps appears too short at each end and reduces the available support to users of the steps ”

    Source location

    Richard HEDGES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  4. Manchester South

    AI-generated summary

    Richard John Whale · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Richard John Whale died at Salford Royal Hospital after suffering a head injury in a fall down the exit stairs at Old Trafford football ground. The concerns included stewards impeding the exit and obstructing access to handrails, inadequate guidance on steward placement, non-compliance with the stewards’ code of conduct, and a lack of evidence of regular audits. There was also no mechanism to discuss or monitor whether recommendations issued after his death had been followed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of guidance on steward placement to keep handrail access clear

    Wider context from the report

    “3. The green guide does not give guidance as to placement of stewards or suggest best practice to avoid stewards blocking access to the handrails. It was accepted during the course of the inquest that the role and placement of stewards was vital to ensuring the safety of the public at football matches. ”

    Source location

    Richard John Whale · 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

    Publish the sixth edition of the Green Guide with expanded guidance on vomitories, steward positioning, widths, control measures, and steward training.

    Verbatim wording from the response

    “The SGSA has since published the latest 6th edition of the Green Guide in October 2018. This latest edition expands upon the guidance in the 5th edition and includes specific guidance on vomitories and the positioning of stewards (section 9.8), vomitory widths (section 9.9) and vomitory control measures (section 9.10). It recognises that the width of a vomitory, and of gangways leading to a vomitory, are key control measures (section 9.9). Furthermore, Chapter 4 highlights that safety at sports grounds relies to a great extent upon the deployment of an appropriate number of well trained and suitably equipped stewards, with section 4.6 outlining stewards’ duties and section 4.10 detailing current stewards training and assessment processes. The new edition of the Green Guide has informed the SGSA’s engagement with Trafford MBC and MUFC.”

    Source location

    2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
    Page 2 · response
    Published 21 December 2018

    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

    Amend Green Guide section 9.8e to specifically address spectator access to handrails during vomitory ingress and egress.

    Verbatim wording from the response

    “In light of the concerns you have raised the SGSA is amending the Green Guide so that section 9.8e makes a specific reference to access to handrails in the context of vomitories and the positioning of stewards. The relevant extract is below, with the proposed new wording shown in italics:”

    Source location

    2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
    Page 2 · response
    Published 21 December 2018

    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

    Deliver continuing steward briefings with increased emphasis on the Code of Conduct, situational awareness, customer engagement, unimpeded vomitories and accessible handrails.

    Verbatim wording from the response

    “• Briefings are continually ongoing to all stewards, which cover their duties, roles and responsibilities. This information is also included in match day briefing notes. Within these briefings, we have increased the focus on the importance of the provisions of the Stewards Code of Conduct. The briefings place particular emphasis on (i) stewards’ awareness of their surroundings and prevailing situation, (ii) customer engagement, (iii) ensuring that vomitories remain unimpeded at all times, and (iv) ensuring availability of handrails for supporters at all times.”

    Source location

    2018-0404-Response-by-MUFC
    Page 2 · response
    Published 21 December 2018

    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

    Deliver detailed positioning guidance to vomitory stewards covering handrail access, movement to clear passage and maintaining awareness during matches.

    Verbatim wording from the response

    “• In addition, specific steward positioning guidance has been delivered to all stewards who are responsible for vomitory areas which: o provides guidance to ensure that steward positioning allows supporters to use the handrails and to ensure that the stewards facilitate their use; o emphasises the need for stewards to continually alert people coming to use the vomitory and to move accordingly to allow space to pass; and o further emphasises to all stewards that their focus must not be distracted by events taking place on the pitch during the match, in order that they maintain their position and awareness of their surroundings so as to carry out their regulated duties.”

    Source location

    2018-0404-Response-by-MUFC
    Page 2 · response
    Published 21 December 2018

    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

    Conduct proactive checks limiting vomitory staffing to two stewards except in exceptional circumstances and positioning them to maximise handrail accessibility during heavy footfall.

    Verbatim wording from the response

    “• Regular proactive checks have been put in place to ensure that no more than two stewards are present in the vomitory space (save for exceptional circumstances where an additional stewarding presence is required). In periods of heavy footfall, one steward will stay near the head of the vomitory whilst the other will move down inside so as to maximise accessibility of the handrails.”

    Source location

    2018-0404-Response-by-MUFC
    Page 2 · response
    Published 21 December 2018

    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

    Conduct match-by-match proactive and live audits of vomitory steward positioning and compliance with the Stewards Code of Conduct.

    Verbatim wording from the response

    “Nevertheless, we have fully taken on board the concern which has been raised here. Accordingly, as mentioned above in my opening remarks, we have put into place an additional match-by-match system of proactively checking both stewards’ positioning within vomitories and checking compliance by stewards with the Code of Conduct (including live auditing of both issues throughout each match).”

    Source location

    2018-0404-Response-by-MUFC
    Page 4 · response
    Published 21 December 2018

    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

    The SGSA considers Trafford MBC and MUFC’s identified safety issues and steps taken to address them sufficient, subject to ongoing monitoring.

    Verbatim wording from the response

    “Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.”

    Source location

    2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
    Page 1 · response
    Published 21 December 2018

    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

    The content of the Green Guide is a matter for the Sports Grounds Safety Authority, not the Club.

    Verbatim wording from the response

    “The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.”

    Source location

    2018-0404-Response-by-MUFC
    Page 3 · response
    Published 21 December 2018

    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

    The Sports Grounds Safety Authority and DDCMS are expected to provide the substantive response on Green Guide content.

    Verbatim wording from the response

    “The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.”

    Source location

    2018-0404-Response-by-MUFC
    Page 3 · response
    Published 21 December 2018

    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

    The Club remained satisfied that steward positioning was appropriate, supported by established practice and regulator observation, while issuing guidance to codify it.

    Verbatim wording from the response

    “Again, the content of the Green Guide is a matter for the SGSA. The positioning of the stewarding at Old Trafford stadium is something that SGSA and TMBC have had (and continue to have) many opportunities to observe and advise upon. Neither organisation has ever indicated to the Club that the positioning of the stewards within the vomitories (which is standard practice across most if not all major football stadia) is a cause for concern. Indeed, I understand that at the inquest the evidence from TMBC was that in their opinion stewards need to be located in the position in question for safety reasons; this concurs with our own view and with long-standing practice. However, in view of the concern raised in the Report we have very carefully reviewed the position.”

    Source location

    2018-0404-Response-by-MUFC
    Page 3 · response
    Published 21 December 2018

    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

    Absence of a handrail on steps

    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 position was interpreted

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

    PFD Monitor interpretation

    A handrail cannot readily be installed because the narrow path would be further obstructed and the adjoining walls are unsuitable for attachment.

    Verbatim wording from the response

    “Turning to the provision of handrails; as mentioned in previous correspondence, due to the narrowness of the path it would be very difficult to install a handrail, because this would further reduce the width, which could be viewed as an obstacle by some footpath users. In any event the hand rails would need to be attached to the abutting walls, which are not within the County Council’s ownership. The walls have been inspected and are considered to be unsuitable for attaching rails of this nature because of their age, and in places the walls are in fairly fragile condition.”

    Source location

    2014-0206-Response-by-Durham-County-Council
    Page 1 · response
    Published 8 May 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026