Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0206, written 8 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2014 |
|---|---|
| Reference | 2014-0206 |
| Deceased | Sopefoluwa Peters |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
3 | INVESTIGATION and INQUEST 1 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Durham County Council, County Hall, Durham DH1 5UQ $$$ _______| CORONER lam Andrew Tweddle, Senior Coroner, for the coroner area of County Durham and Darlington ee | CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. (see attached sheet) On 17" of December 2013 | commenced an investigation into the death of Sopefoluwa Babtunda Peters, 20 years old. The investigation concluded at the end of the Inquest on 9" of April 2014 The conclusion of the inquest was Accidental Death. CIRCUMSTANCES OF THE DEATH Mr Sope Peters who died on the 30" of October 2013 by drowning in the River Wear is likely to have entered the river after falling into the river after descending steep steps in an area known as Drury Lane, Durham City to the riverside path. He was under the influence of alcohol at the time. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The steps are steep, poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm's high and does not create much of a safety barrier. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such actlon. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3” July 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons aa | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary | form. He may send a copy of this report to any person who he believes may find it useful | or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. aes ee }9 | 8" May 2014 ——— UNAS Andrew Tweddle LLB HM Senior Coroner County Durham and Darlington
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Direct Tel: Your ref: County Council <A és Ourref: RED/T&CS/14 Mr Andrew Tweddle LL.B. HM Senior Coroner for County Durham and Darlington H.M Coroner's Office PO Box 282 Bishop Auckland Co Durham DL144FY 3 June 2014 Dear Sir Re: Sopefoluwa Babtunde Peters, deceased ! refer to your letter dated the 8" of May 2014 enclosing your Regulation 28 report, following the conclusion of the inquest into the death of Mr Peters. Careful consideration has been given to the matters of concem which you have raised in your report at paragraph 5 and the County Council's response is set out below. With reference to your concem about the steepness of the steps and lack of handrail on Drury Lane; the lane has been inspected by the County Council's Rights of Way Officer and he is satisfied that the steps themselves are in a good state of repair. It Is acknowledged that these steps are steep, requiring some care when descending them. However, these steps have been in existence for a considerable period of time and to our knowledge there has been only one previous report of a tripping or slipping accident, and that defect was rectified. It is in any event difficult to see how these steps could be modified as the path is too narrow to achieve any meaningful alleviation of this slope. Tuming to the provision of handrails; as mentioned in previous correspondence, due to the narrowness of the path it would be very difficult to install a handrail, because this would further reduce the width, which could be viewed as an obstacle by some footpath users. In any event the hand rails would need to be attached to the abutting walls, which are)not within the County Council's ownership. The walls have been inspected and are considered to be unsuitable for attaching rails of this nature to because of their age, and in places the walls are in fairly fragile condition. continued/... Durham County Council, County Hall, Durham DH1 5UQ Telephone: 03000 260000 www.durham.gov.uk iGO 33i7' Council of the Year Page 2 of 2 Whilst lighting the location may assist, it would result in a lit area leading to unlit riverside paths, creating greater contrast between areas of light and dark. It is felt that lighting all the riverbank paths wouid be both impractical and inappropriate due to the detrimental effect on the setting of the World Heritage Site. On balance it is not considered helpful to fight this location. ! can confirm that whilst no action is being proposed in respect of the above mentioned matters, the Council will be Installing a timber barrier in the riverside footpath, adjacent to the wall opposite the exit from Drury Lane. The installation of a banier should reduce any potential risk of someone falling or running down the steps and going over the wall into the river at this location. This barrier will be placed within the footpath itself, as the path is within the control of the County Council. It is anticipated that this barrier will be installed within the next two weeks. The County Council will also be undertaking a risk assessment along sections of the river bank. This assessment will include representatives from the police who will identify locations, from their loca! knowledge of where there is a volume of evening and night time activity. If further risks are identified these will be assessed and action will be taken by the County Council to minimise such risks as is considered appropriate. This was a tragic case which highlights how young adults, in particular can come to harm when they are travelling alone at night significantly under the influence of alcohol which is an intrinsicaily perilous state. Addressing the risks caused by alcohol is a priority of this council and its partner agencies and ! attach links to the Alcohol Harm Reduction Strategy: the County Durham Safe partnership pages on alcohol reductions and links to work being carried out in the city centre. htto.//www.durham.gov.uk/pages/service.aspx? Serviceid=8108 htipv//www.coun rhampartn ip.co.uk/P: P-Alcoho!: aspx http)/Awww.countydurhambestbamone.co.uk/pages/NightSafelnitiatives.aspx ; Yours sincerely Head of Transport and Contract Services
See every Prevention of Future Deaths report matching Andrew Tweddle, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.