Recipient

Gravesham Borough Council

First report 19 Dec 2023•Latest report 19 Dec 2023

Recipient record

Reports, concerns and published responses

Local government · English district council. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 5

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Dec2023
North West Kent
Concerns raised4
1. Failure to provide a handrail with sufficient end support on the external staircase
2. Lack of highlighting on external staircase step edges
3. Poor lighting of the external staircase area
1. Failure to maintain a slip-resistant external staircase surface
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remove the steps and platform from the walkway to return it to ground level.
  Stated planned
Respondent positions 1
1. Position
  Completed works are considered sufficient to address all concerns raised in the Regulation 28 report.
  Existing arrangements considered sufficient
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. The report was sent to Gravesham Borough Council; that does not assign responsibility.
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 ”
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 Gravesham Borough Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of highlighting on external staircase step edges
Wider context from the report
“(1)The short external staircase where Mr Hedges fell is constructed of concrete steps which are showing signs of wear/weathering. The steps are not coated with a non slip surface and the edges of the steps do not have highlighting to increase awareness. ”
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 Gravesham Borough Council; that does not assign responsibility.
PFD Monitor interpretation
Poor lighting of the external staircase area
Wider context from the report
“(3) The current lighting of the area of the external staircase is poor. ”
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 Gravesham Borough Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain a slip-resistant external staircase surface
Wider context from the report
“(1)The short external staircase where Mr Hedges fell is constructed of concrete steps which are showing signs of wear/weathering. The steps are not coated with a non slip surface and the edges of the steps do not have highlighting to increase awareness. ”
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

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

Reports, concerns and published responses

Reports over time

Concerns raised4

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

Lack of highlighting on external staircase step edges

Poor lighting of the external staircase area

Failure to maintain a slip-resistant external staircase surface

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.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 1

Respondent positions 1