PFD report

Stanislawa Kmiecik · Prevention of Future Deaths report

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Issued 25 Jul 2019•Nottinghamshire

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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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.

Report evidence summary

Concerns raised7

  1. Uneven and deteriorated surface surrounding the mezzanine openings
    Part of recurring concern: Unsafe walking surfaces creating trip hazards
  2. Lack of signage highlighting the risk of fall
    Part of recurring concern: Inadequate control of falls risks
  3. Failure to prevent objects falling through the mezzanine opening
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.6

  1. Action

    Place no-unauthorised-access signage beside the gate.

    Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.
  2. Action

    Restrict access beyond the gate to authorised staff and extend the instruction to new staff.

    Stated by Urbn UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2019.
  3. Action

    Remove movable items from beyond the gate.

    Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.

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

  1. Position

    The incident was almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.

    Stated by Urbn UK LimitedDisputes 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

Uneven and deteriorated surface surrounding the mezzanine openings

Wider context from the report

“(6) The surface area surrounding the openings is uneven and in a state of disrepair, posing a trip hazard to any member of staff or the public in the vicinity and increasing the risk of inadvertently falling from height. ”

Is this part of a recurring concern?

Yes — Unsafe walking surfaces creating trip hazards.

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

Lack of signage highlighting the risk of fall

Wider context from the report

“(2) There is no signage highlighting the risk of fall ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Failure to prevent objects falling through the mezzanine opening

Wider context from the report

“(7) Further, any item that is dropped in that area, or is thrown over the gate, could fall through the opening and onto staff/members of the public below. ”

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

Failure to prevent access to the mezzanine openings

Wider context from the report

“(3) Whilst the area is cordoned off from the main shop floor by way of a locked mesh gate and some scaffolding type posts, it remains possible for staff and/or members of the public to access the area. ”

Is this part of a recurring concern?

Yes — Failure to prevent public access to closed or restricted hazardous sites; Inadequate fall protection at mezzanine and balcony openings; Inadequate physical barriers preventing access to dangerous drops or areas.

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

Accessible 18-foot drop between the mezzanine and basement shop floor

Wider context from the report

“(1) There is a drop of some 18 feet between the mezzanine floor and the basement shop floor below that is accessible via a gate from the shop floor where persons are free to roam ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

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

Failure to prevent inexperienced staff from accessing the restricted area

Wider context from the report

“(4) Although members of staff have been told not to access this area of the shop, I remain concerned that in the absence of signage, a new or inexperienced member of staff may seek access to that area either by unlocking the gate or by climbing over the gate (as has happened in the past). ”

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

Lack of fall protection below the mezzanine openings

Wider context from the report

“(5) If a member of staff or the public were to access the area, there remains a risk of falling from height as there is no safety netting or other safety structure below either of the two openings in the mezzanine floor. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Inadequate fall protection at mezzanine and balcony openings; Inadequate physical barriers preventing access to dangerous drops or areas.

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

Place no-unauthorised-access signage beside the gate.

Verbatim wording from the response

“• signage has been placed adjacent to the gate indicating no unauthorised access ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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

Restrict access beyond the gate to authorised staff and extend the instruction to new staff.

Verbatim wording from the response

“• immediately after the incident all moveable items beyond the gate were removed and all members of staff were instructed not to access the area beyond the gate unless authorised to do so. That instruction not to access the area beyond the gate has been repeated and will cover new members of staff ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019

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

Remove movable items from beyond the gate.

Verbatim wording from the response

“• immediately after the incident all moveable items beyond the gate were removed and all members of staff were instructed not to access the area beyond the gate unless authorised to do so. That instruction not to access the area beyond the gate has been repeated and will cover new members of staff ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019

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

Replace the scaffolding with high railings throughout.

Verbatim wording from the response

“• removal of all of the scaffolding and replaced with high railings throughout ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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

Infilling the voids with steel plates.

Verbatim wording from the response

“• infilling the voids with steel plates ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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

Replace the broken gate lock.

Verbatim wording from the response

“• the broken lock was replaced on Monday 15 April 2019 ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019

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 almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.

Verbatim wording from the response

“We do not wish to pre-judge the evidence that will be heard at the inquest. However, it does seem plain that the cause of the incident was almost certainly a deliberate attempt by the deceased to put herself in a position of danger and potentially take her own life. There can be no other credible explanation for the individual unsecuring the gate or climbing over the gate and then going beyond the scaffolding. No member of the public has ever attempted previously to access the area beyond the gate.”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019

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.3

  1. 1

    Purchase and secure harness equipment in a locked display-room cupboard.

    Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.
  2. 2

    Install a pulley system to lower grids safely when updating visual displays.

    Stated by Urbn UK LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 6 September 2019.
  3. 3

    Train authorised staff to use harnesses when working beyond the gate.

    Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.

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

Purchase and secure harness equipment in a locked display-room cupboard.

Verbatim wording from the response

“• authorised members of staff have been trained in the use of harnesses when working in the area beyond the gate. Harness equipment has been purchased and is stored in a locked cupboard in the display room.”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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 a pulley system to lower grids safely when updating visual displays.

Verbatim wording from the response

“• installation of a pulley system to lower the grids to a safe height to update the visual displays ;”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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

Train authorised staff to use harnesses when working beyond the gate.

Verbatim wording from the response

“• authorised members of staff have been trained in the use of harnesses when working in the area beyond the gate. Harness equipment has been purchased and is stored in a locked cupboard in the display room.”

Source location

2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019

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

Official responses located
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Data last updated 7 September 2026