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
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Investigate the effectiveness and practicality of seasonal or more frequent releveling of beach sand and shingle.
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Action
Complete new and updated risk assessments for Felixstowe Promenade, including consideration of risks to mobility scooter users.
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Action
Monitor beach levels at promenade road entrances and ramps for 12 months to inform further safety measures.
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Action
Renew existing hazard line markings along the promenade.
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Action
Install signage at locations where beach levels fluctuate and create a fall risk.
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Action
Commission a full disability access audit of the promenade and surrounding area from a Centre for Accessible Environments-accredited assessor.
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Action
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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× 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 East Suffolk Council; that does not assign responsibility.
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.
” Open source 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 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
Open published response
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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
Open published response
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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
Open published response
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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 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
Open published response
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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
Open published response
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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 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
Open published response
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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
Open published response
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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 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
Open published response
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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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations