13 Jun 2018 Karen Diane Wiggins · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1 Suicidal falls from multi-storey car parks View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Karen Diane Wiggins · 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
Karen Wiggins died instantly after jumping from an upper floor of the Fleming Way Car Park on 1 December 2017. The report raised concerns about previous suicidal falls from multi-storey car parks in Swindon, including the same car park, and called for a Council investigation into possible preventative measures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Suicidal falls from multi-storey car parks
Wider context from the report “I learned that there had been a number of suicidal falls from multi storey car parks in Swindon, with previous occurrences at the Fleming Way Car Park , together with a number of instances where suicidal individuals had been successfully talked down uninjured. An investigation by the Council is called for. Inter alia such an investigation might explore the possibility of creating physical barriers to prevent individuals jumping from height and / or the posting of notices giving contact details for the Samaritans, a strategy that has been employed at some railway stations in an attempt to avoid suicidal leaps in front of trains.
” Open source report
20 Jul 2017 Nina MAGGS · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 3 Lack of safe visibility and crossing conditions for pedestrians at the junction View source Insufficient all-red crossing time for pedestrians View source Lack of accessible pedestrian crossing signals View source
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Nina MAGGS · 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
Nina MAGGS died at the scene from multiple traumatic injuries after being struck by an Iveco road sweeper while attempting to cross Hyde Road at a junction in Swindon on 23 February 2017. The report raises concerns about the safety of pedestrians at the junction, including inadequate pedestrian signals and insufficient time to cross safely, particularly for people with physical, visual or hearing impairments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safe visibility and crossing conditions for pedestrians at the junction
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road . It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death . Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment. In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction.
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” 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 Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient all-red crossing time for pedestrians
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road. It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death. Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment. In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction .
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” 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 Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible pedestrian crossing signals
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road. It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death. Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment . In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction.
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” 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 Analyze signal operation and traffic levels, assess alternatives, and develop preliminary technology and civil-engineering designs for pedestrian signal phases.
Verbatim wording from the response “Following the fatal accident an analysis of the current operation of the traffic signals at Kingsdown Crossroads was carried out, including an analysis of the current traffic levels. A scheme to” Source location 2017-0216-Response-by-Swindon-Borough-Council_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and obtain approval for a briefing recommending further investigation and stakeholder and public consultation on the proposed pedestrian signal scheme.
Verbatim wording from the response “Since receipt of the Regulation 28 notice, further work has included the preparation and sign off of a briefing note for the Council’s Cabinet Member for Communities and Place and sign off by myself as Head of Highways and Transport. This has recommended and approved a proposal to take the proposed scheme forward to further investigation and consultation with stakeholders and the public.” Source location 2017-0216-Response-by-Swindon-Borough-Council_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct stakeholder and public consultation on the pedestrian signal proposals and analyze feedback to inform subsequent decisions.
Verbatim wording from the response “The next stage is therefore for the Council to undertake stakeholder consultation with regard to the proposals and the balance between those aspects of safety and impact noted above.” Source location 2017-0216-Response-by-Swindon-Borough-Council_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The junction’s constrained sight lines and pavement space make alternative pedestrian safety options undeliverable or less beneficial than the proposed approach.
Verbatim wording from the response “A range of alternative options have been considered for the junction. These have included a do nothing option, zebra crossings, different pedestrian phasing arrangements and the potential to significantly widen or expand the junction itself. The junction is however very constrained in relation to sight lines and pavement space and each of these options have been ruled out on either benefit or deliverability grounds when compared to the current proposed way forward” Source location 2017-0216-Response-by-Swindon-Borough-Council_Redacted
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12 Mar 2014 Wendy Bernadine BROWN · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 4 Inadequate signposting of Adult Care Public Services and funding routes View source Delays in processing applications and implementing care packages causing gaps in carer support View source Lack of appeal routes for some care and funding decisions View source Delays in processing applications and implementing care packages causing gaps in carer support View source See 1 more concern
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Wendy Bernadine BROWN · 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
Wendy Bernadine BROWN had suffered from depression and had been the full-time carer of her severely disabled granddaughter. After a period of approximately 18 months without support or respite, Wendy died by hanging at her home during the late evening of 27 August into the morning of 28 August 2013. The concerns included delays and gaps in adult social care support, the adequacy of signposting and funding information, the timeliness of processing care applications, and the availability of appeal routes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate signposting of Adult Care Public Services and funding routes
Wider context from the report “a) During the course of the Inquest I heard how Swindon Borough Council outsourced their Adult Care to an organisation called SEQOL and that that organisation commenced effective operation in November 2011 with relevant social workers transferring under the Transfer Undertaking Regulations to the new organisation. I heard evidence from the Interim Company Secretary at SEQOL and in relation to the delay as regards the implementation of care packages and I was concerned to learn that some 18 months effectively elapsed where Wendy was effectively solely responsible for the care of ████ her severely disabled granddaughter, without respite care or care support. I am concerned as regards the adequacy of the measures taken by the commissioners to ensure that relevant Adult Care Public Services are effectively signposted so that the public are aware of available services and more importantly that the funding routes are also highlighted. The system of social adult care is a complicated maze and I have tried to keep this concern as simple as possible. I would be grateful if you could please review the matter having regard to this particular case with a view to establishing whether or not there are any lessons to be learned following the death of Wendy. I understand that no review has been undertaken to date and I am concerned that such delay could place another carer under similar strain and that that scenario could directly contribute to another person’s death if they were then to take their own life whilst packages were being arranged.
” 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 Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in processing applications and implementing care packages causing gaps in carer support
Wider context from the report “a) During the course of the Inquest I heard how Swindon Borough Council outsourced their Adult Care to an organisation called SEQOL and that that organisation commenced effective operation in November 2011 with relevant social workers transferring under the Transfer Undertaking Regulations to the new organisation. I heard evidence from the Interim Company Secretary at SEQOL and in relation to the delay as regards the implementation of care packages and I was concerned to learn that some 18 months effectively elapsed where Wendy was effectively solely responsible for the care of ████ her severely disabled granddaughter, without respite care or care support . I am concerned as regards the adequacy of the measures taken by the commissioners to ensure that relevant Adult Care Public Services are effectively signposted so that the public are aware of available services and more importantly that the funding routes are also highlighted. The system of social adult care is a complicated maze and I have tried to keep this concern as simple as possible. I would be grateful if you could please review the matter having regard to this particular case with a view to establishing whether or not there are any lessons to be learned following the death of Wendy. I understand that no review has been undertaken to date and I am concerned that such delay could place another carer under similar strain and that that scenario could directly contribute to another person’s death if they were then to take their own life whilst packages were being arranged.
” 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 Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appeal routes for some care and funding decisions
Wider context from the report “c) I am also concerned that there appears to be no ability to appeal against your decision in some areas . CHC funding I was told does have an appeal route however other areas require a fresh application to be made with substantive new information . I would be grateful from the point of ensuring that the right decisions are made as to whether a review could look on this area as well please. The decisions you make impact greatly on carers lives and of course those that they care for.
” 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 Swindon Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in processing applications and implementing care packages causing gaps in carer support
Wider context from the report “b) I am also concerned and would be grateful if you could please review the timeliness within which applications both from the funding perspective and service nature are processed under your administration . It concerns me that whilst applications are being processed or even assessments themselves are being undertaken (as I understand it even as part of transition arrangements some organisations will not assess the individual until they are 18) that there is inevitably going to be a gap in support for carers whilst the application is being determined until the care package if approved is implemented . This concerns me in a case where you have an individual such as ███████ who quite clearly requires an extensive support and care package. I appreciate that instances such as ████ are in the extreme but I am concerned that Wendy and █████ situation is unlikely to be unique.
” 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 Finalise and relaunch the revised Transitions Protocol to reflect the extended statutory transition age.
Verbatim wording from the response “████████ case was managed through the Transitions process. Swindon Borough Council along with partner organisations had, and continues to have a Transitions Protocol in place. This involves the Adult Transitions team (a SEQOL Team) in the planning of young people in transitions from year 9 (14 years) onwards. Changes to legislation formally extending the transitions process for young people to age 25 has required the Transitions protocol to be revisited and re-launched. Work is in progression finalising the new protocol, whilst transitions is not uniquely the preserve of Learning Disabilities the majority of young people in transition have a learning disability with the management of the Transitions and transitions workers resting in SEQOLs Learning Disabilities Team. Transition therefore forms an important part of the Learning Disability Workstreams referred to above.” Source location 2014-0113-Response-by-Swindon-Borough-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allow indicative budgets to be agreed pending additional information when services above the indicative budget are requested, enabling timely service provision.
Verbatim wording from the response “An immediate action taken is that, were services over and above the indicative budget are requested, the indicative budget can be agreed pending any additional information required to ensure that some services are in place in a timely manner. As detailed above, services were agreed for ███ in September 2011 however her grandmother did not feel that the services available in Swindon could meet her granddaughter’s needs. Direct Payments were available to WB from November 2011, she had originally identified a group of personal assistants that she wanted to provide services to ████████. These Personal Assistants subsequently did not take up the offer from Wendy and during this time Direct Payments continued to be accumulated within her designated account whilst she sought alternative services.” Source location 2014-0113-Response-by-Swindon-Borough-Council
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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 Provide commissioner-led pre-verification coaching to Learning Disability staff on presenting required information for timely funding decisions.
Verbatim wording from the response “consideration by exceptions panel, but overtime the numbers have significantly decreased allowing the Exceptions panel to focus on the most complex of cases. Particular reference is made to the timeliness within which applications both from the funding perspective and service nature were processed. Prior to, and continuing after, the death of WB support was provided by SBC commissioners to the Learning Disability team, not exclusively to, but including the Transitions workers. The purpose of this support was to provide a focus on compliance with the Adult Services assessment requirements so that applications from the Learning Disability team could be dealt with efficiently without repeated queries and clarifications being necessary before public funds could be allocated.” Source location 2014-0113-Response-by-Swindon-Borough-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing contractual, audit, verification and improvement arrangements are considered sufficient to address delays and complexity in adult social care decision-making.
Verbatim wording from the response “The Verification process is supported by a contracts team and dedicated brokers and placement officers who access the services that are identified in support plans. The contracts team are involved in the establishing of service arrangements and the monitoring of such contracts. There are many commissioning challenges for Adult Social Care reported nationally, and Swindon is not immune to such challenges. We believe that the structure allows for these challenges to be addressed and the commitment to the workstreams in the Learning disability area demonstrates our commitment to improve in this area. In addition we have recognised that further development of the local service offer is required and a Market Position Statement is in draft form and due to be published in the coming months.” Source location 2014-0113-Response-by-Swindon-Borough-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing exceptions-panel, complaints and continuing healthcare appeal arrangements are considered sufficient to address the reported lack of an appeal process.
Verbatim wording from the response “5c)
In this paragraph you make reference to the lack of appeal process with particular reference to CHC funding. As referred to above there is an exceptions panel made up with Senior Managers which deals with cases where resolution has not been achieved by the Verifications team with SEQOL. Should there be unresolved matters after exceptions panel has considered the matter then the Adult Social Care complaints procedure is available to Service users and Carers alike.” Source location 2014-0113-Response-by-Swindon-Borough-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations