Samuel Patrick CLARKE · Prevention of Future Deaths report

On 8 January 2018, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Samuel Patrick Clarke, aged 19 years. The investigation concluded at the end of the inquest on 15 June 2018.

I made a determination that Samuel’s death was the result of an accident, when he fell from height whilst on a construction site at 1 Bank Street in London at approximately 2.30am on New Year’s Day 2018, and was not found until the following day.

Samuel left a 2017 New Year’s Eve celebration and ended up gaining access to the One Bank Street site in the early hours of New Year’s Day. He made himself known to security guards but then ran off. CCTV was checked and there was no sign of him leaving the site. A search ensued but the police were not called.

He was not found until 2 January 2018, by which time he was dead. It was not the intent of his fall that killed him and so if he had been found earlier, he might have been saved. His medical cause of death was as follows.

1a postural asphyxia
1b fall and traumatic injury
1c ethanol intoxication

1. I was told by the senior construction manager of Canary Wharf Contractors Limited that the gap under the turnstile where Samuel accessed the site has been reduced by 5cms since his death, from 30cms to 25cms, by adding a strip of plywood to the bottom.

I am concerned that the turnstile is still accessible to unauthorised personnel – including to children. I heard at inquest that there are 800 tradespeople on site and I wonder whether one of them has the skills to make the turnstile secure?

2. I heard evidence that, since Samuel’s death, site security officers have been given instructions to call the police if they are aware of an intruder on site who has not been located. However, no consideration has been given to a company contingency plan, for example to draft in staff who are familiar with the site to help with a search. Would this be possible?

3. The site security officers explained to me that they were equipped with battery operated regular sized torches, rather than large flashlights. No consideration has been given to improving their equipment in this regard. Could it be?