PFD report

Stephen James LAWSON · Prevention of Future Deaths report

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Issued 13 Aug 2018•Bedfordshire and Luton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Crash barrier usable as a step to cross the external wall
  2. Insufficient availability and visibility of Samaritans signs
    Part of recurring concern: Inadequate suicide-prevention signage at public locations
  3. Ease of access to the external barrier wall
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Have a competent professional assess steel barriers and caging arrangements across all car parks.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
  2. Action

    Carry out a full audit of signage across the multi-storey car parks, including Samaritans signage.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
  3. Action

    Complete a visual audit of all multi-storey car parks, identifying barrier damage and other safety issues.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Access between the crash barrier and perimeter wall is difficult because steel caging encloses the barrier.

    Stated by Bedford Borough CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Crash barrier usable as a step to cross the external wall

Wider context from the report

“(3) If a person accesses the space between the crash barrier and the external wall, the crash barrier can be used as a step to cross the external wall; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient availability and visibility of Samaritans signs

Wider context from the report

“(4) There are very few ‘Samaritans’ signs, and these generally are only visible if a pedestrian is exiting the car park ”

Is this part of a recurring concern?

Yes — Inadequate suicide-prevention signage at public locations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Ease of access to the external barrier wall

Wider context from the report

“(2) It is surprisingly easy to gain access to the external barrier wall; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Risk of persons jumping from the car park

Wider context from the report

“(1) This is not the first person to have jumped from this car park; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Have a competent professional assess steel barriers and caging arrangements across all car parks.

Verbatim wording from the response

“Action Point 1 In response to the findings of the audit carried out on 31st August 2018 I have instructed that all steel barriers and steel chaffing arrangements in all car parks are assessed by a competent professional, and where repairs may be identified these repairs will be carried out using a risk based approach to any matters that are identified, focussing on areas and locations that have a higher use, access/egress etc. Given the open nature of these buildings there is an element of wear and tear that is addressed as and when required. It is envisaged that any works identified will be completed within three months of the date of this letter.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 5 · response
Published 4 October 2018

Open published response

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

Carry out a full audit of signage across the multi-storey car parks, including Samaritans signage.

Verbatim wording from the response

“There is some signage located within the MSCPs that promote the services of the Samaritans for persons that may need to use their confidential counselling services. Nevertheless, I have requested that a full signage audit be carried out as is set out below.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 4 · response
Published 4 October 2018

Open published response

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 a visual audit of all multi-storey car parks, identifying barrier damage and other safety issues.

Verbatim wording from the response

“As a result of the recent incident concerning Mr Lawson a visual audit of all MSCPs was carried out on 31 August 2018. At the time of the audit the condition of the steel barriers was considered to be in good condition overall, however it was noted in certain places that damage had occurred at a small number of locations where protective plates had become loose/missing on the corner junctions of the steel barriers, any repairs will be addressed as part of planned remedial works (see Action Point 1 below).”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 4 · response
Published 4 October 2018

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

Access between the crash barrier and perimeter wall is difficult because steel caging encloses the barrier.

Verbatim wording from the response

“2) It is surprisingly easy to gain access to the external barrier wall”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 3 · response
Published 4 October 2018

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

The incident was not the first attempted suicide at the Council’s multi-storey car parks.

Verbatim wording from the response

“1) This is not the first person to have jumped from this car park”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 3 · response
Published 4 October 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Provide refresher training and instruction to relevant Parking Services staff on emergency incident responses.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
  2. 2

    Install new lifts at Lurke Street Car Park.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
  3. 3

    Review the multi-storey car park Emergency Procedure.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
  4. 4

    Install additional CCTV cameras on parking levels and in stairwells across all multi-storey car parks.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
  5. 5

    Install reactive lighting throughout all multi-storey car parks.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
  6. 6

    Complete risk assessments for each of the four multi-storey car parks through the annual premises inspection process.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
  7. 7

    Refurbish Allhallows multi-storey car park with improved CCTV, communications, lighting, lifts and fire-control systems.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.

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 refresher training and instruction to relevant Parking Services staff on emergency incident responses.

Verbatim wording from the response

“Action Point 3 The MSCP Emergency Procedure will be reviewed and all relevant staff within Parking Services receive refresher training and instruction regarding the appropriate response required should an emergency incident occur. This training and instruction will be completed with all relevant staff by 31 October 2018.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 5 · response
Published 4 October 2018

Open published response

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 new lifts at Lurke Street Car Park.

Verbatim wording from the response

“In addition to this last year all the MSCPs received additional CCTV cameras on the parking levels and in the stairwells, new reactive lighting was installed throughout all MSCPs and new lifts were installed at Lurke Street Car Park. As stated earlier CEOs routinely inspect the car parks and at least once an hour. All New recruits receive a Level 2 City & Guilds training in Parking Enforcement.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 2 · response
Published 4 October 2018

Open published response

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

Review the multi-storey car park Emergency Procedure.

Verbatim wording from the response

“Action Point 3 The MSCP Emergency Procedure will be reviewed and all relevant staff within Parking Services receive refresher training and instruction regarding the appropriate response required should an emergency incident occur. This training and instruction will be completed with all relevant staff by 31 October 2018.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 5 · response
Published 4 October 2018

Open published response

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 additional CCTV cameras on parking levels and in stairwells across all multi-storey car parks.

Verbatim wording from the response

“In addition to this last year all the MSCPs received additional CCTV cameras on the parking levels and in the stairwells, new reactive lighting was installed throughout all MSCPs and new lifts were installed at Lurke Street Car Park. As stated earlier CEOs routinely inspect the car parks and at least once an hour. All New recruits receive a Level 2 City & Guilds training in Parking Enforcement.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 2 · response
Published 4 October 2018

Open published response

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 reactive lighting throughout all multi-storey car parks.

Verbatim wording from the response

“In addition to this last year all the MSCPs received additional CCTV cameras on the parking levels and in the stairwells, new reactive lighting was installed throughout all MSCPs and new lifts were installed at Lurke Street Car Park. As stated earlier CEOs routinely inspect the car parks and at least once an hour. All New recruits receive a Level 2 City & Guilds training in Parking Enforcement.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 2 · response
Published 4 October 2018

Open published response

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 risk assessments for each of the four multi-storey car parks through the annual premises inspection process.

Verbatim wording from the response

“Action Point 2 I have also instructed that each of the four MSCPs is risk assessed as part of the annual premises/workplace inspection process employed by the Council as part of its ongoing legal duties. These premises/workplace risk assessments will be completed by 31 October 2018.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 5 · response
Published 4 October 2018

Open published response

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

Refurbish Allhallows multi-storey car park with improved CCTV, communications, lighting, lifts and fire-control systems.

Verbatim wording from the response

“Recent examples include a full refurbishment of Allhallows MSCP. The work included new lifts, improved CCTV across all areas of the car park, updated communication systems, upgraded lighting and fire control systems. This work took place in 2015 and won an award from the British Parking Association as the Best Car Park Refurbishment in 2015.”

Source location

2018-0264-Response-by-Bedford-Borough-Council
Page 2 · response
Published 4 October 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026