Gravesham Borough Council

Local government · English district council

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First report 19 Dec 2023•Latest report 19 Dec 2023

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
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
4

Across all linked responses

Stated actions
5

Described in responses

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.

  1. 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. 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
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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