Bedford Borough Council

Local government · English unitary authority

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First report 9 May 2014•Latest report 13 Aug 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
6

Across all linked responses

Stated actions
22

Described in responses

Concerns and recipient responses

Statements from Bedford Borough Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    Stephen James LAWSON · 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

    Stephen James LAWSON, aged 62, was witnessed jumping from the fourth floor of the Luke Street Multi Storey Car Park in Bedford and died at the scene. Concerns included the ease of accessing the external barrier wall, the ability to use the crash barrier to cross it, the history of previous jumps, and the limited visibility of Samaritans signs.

    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. The report was sent to Bedford Borough Council; that does not assign responsibility.

    PFD Monitor interpretation

    Crash barrier usable as a step to cross the external wall

    Wider context from the report

    “(3) If a person accesses the space between the crash barrier and the external wall, the crash barrier can be used as a step to cross the external wall; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Borough Council; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient availability and visibility of Samaritans signs

    Wider context from the report

    “(4) There are very few ‘Samaritans’ signs, and these generally are only visible if a pedestrian is exiting the car park ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Borough Council; that does not assign responsibility.

    PFD Monitor interpretation

    Ease of access to the external barrier wall

    Wider context from the report

    “(2) It is surprisingly easy to gain access to the external barrier wall; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Borough Council; that does not assign responsibility.

    PFD Monitor interpretation

    Risk of persons jumping from the car park

    Wider context from the report

    “(1) This is not the first person to have jumped from this car park; ”
    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

    Have a competent professional assess steel barriers and caging arrangements across all car parks.

    Verbatim wording from the response

    “Action Point 1 In response to the findings of the audit carried out on 31st August 2018 I have instructed that all steel barriers and steel chaffing arrangements in all car parks are assessed by a competent professional, and where repairs may be identified these repairs will be carried out using a risk based approach to any matters that are identified, focussing on areas and locations that have a higher use, access/egress etc. Given the open nature of these buildings there is an element of wear and tear that is addressed as and when required. It is envisaged that any works identified will be completed within three months of the date of this letter.”

    Source location

    2018-0264-Response-by-Bedford-Borough-Council
    Page 5 · response
    Published 4 October 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

    Carry out a full audit of signage across the multi-storey car parks, including Samaritans signage.

    Verbatim wording from the response

    “There is some signage located within the MSCPs that promote the services of the Samaritans for persons that may need to use their confidential counselling services. Nevertheless, I have requested that a full signage audit be carried out as is set out below.”

    Source location

    2018-0264-Response-by-Bedford-Borough-Council
    Page 4 · response
    Published 4 October 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

    Complete a visual audit of all multi-storey car parks, identifying barrier damage and other safety issues.

    Verbatim wording from the response

    “As a result of the recent incident concerning Mr Lawson a visual audit of all MSCPs was carried out on 31 August 2018. At the time of the audit the condition of the steel barriers was considered to be in good condition overall, however it was noted in certain places that damage had occurred at a small number of locations where protective plates had become loose/missing on the corner junctions of the steel barriers, any repairs will be addressed as part of planned remedial works (see Action Point 1 below).”

    Source location

    2018-0264-Response-by-Bedford-Borough-Council
    Page 4 · response
    Published 4 October 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

    Access between the crash barrier and perimeter wall is difficult because steel caging encloses the barrier.

    Verbatim wording from the response

    “2) It is surprisingly easy to gain access to the external barrier wall”

    Source location

    2018-0264-Response-by-Bedford-Borough-Council
    Page 3 · response
    Published 4 October 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 incident was not the first attempted suicide at the Council’s multi-storey car parks.

    Verbatim wording from the response

    “1) This is not the first person to have jumped from this car park”

    Source location

    2018-0264-Response-by-Bedford-Borough-Council
    Page 3 · response
    Published 4 October 2018

    Open published response

  2. 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. The report was sent to Bedford Borough Council; that does not assign responsibility.

    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 ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Borough Council; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on voluntarily supplied passenger health and mobility information instead of formal assessment

    Wider context from the report

    “(2) That details of a passenger’s health and/or mobility (for the purpose of risk assessing the passenger’s safety when accessing and egressing the vehicle) is dependant upon information supplied voluntarily by the passenger and/or his family rather than by a formal assessment ”
    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

    Require a client-specific risk assessment by the Social Care Transport Team for every non-ambulant client.

    Verbatim wording from the response

    “A newly redesigned Client Transport Referral Form has also been devised by the Transport Operations Group, in conjunction with Adult Services. The form which has been re-designed through consultation with our Occupational Therapists will focus on the person’s functional ability and will be used for initial transport requests, as well as requests for reinstatement of the transport service when there has been a break in service due to medical reasons. This new form will capture information taken from the person/family member and will help to determine whether the reinstatement of the previous transport arrangements are appropriate. The new proposed process also includes a requirement for a client specific risk assessment to be conducted by the Social Care Transport Team for every client who is not ambulant. The redesigned referral form will be introduced by 14 July 2014.”

    Source location

    2014-0223-Response-by-Bedford-Borough-Council
    Page 2 · response
    Published 9 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

    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

    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

    Implement the new transport risk-assessment controls by 14 July 2014.

    Verbatim wording from the response

    “A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

    Source location

    2014-0223-Response-by-Bedford-Borough-Council
    Page 2 · response
    Published 9 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

    Redesign transport risk assessments for boarding and exiting vehicles and cross-reference them to safe systems of work.

    Verbatim wording from the response

    “A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

    Source location

    2014-0223-Response-by-Bedford-Borough-Council
    Page 2 · response
    Published 9 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

    Introduce client-specific risk assessments for transport passengers.

    Verbatim wording from the response

    “A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

    Source location

    2014-0223-Response-by-Bedford-Borough-Council
    Page 2 · response
    Published 9 May 2014

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026