Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0291, written 28 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jun 2014 |
|---|---|
| Reference | 2014-0291 |
| Deceased | Ahmad Khan |
| Coroner | Donald Coutts-Wood |
| Coroner area | South Yorkshire (West) |
| 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Q-Park Limited
2. Sheffield City Council (Planning)
1 | CORONER
i am Donald Stewart Coutts-Wood, assistant coroner, for the coroner area of South
Yorkshire (West).
2° | 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.
(1) Where —
(a) A senior coroner has been conducting an investigation under this Part
into a person’s death
(b) Anything revealed by the investigation gives rise to a concern that
circumstances creating a risk of other deaths will occur, or will continue to exist, in the
future, and
(c) In the coroner’s opinion, action should be taken to prevent the occurrence or
continuation of such circumstances, or to eliminate or reduce the risk of death created
by such circumstances, the coroner must report the matter to a person who the coroner
believes may have power to take such action.
(2) A person to whom a senior coroner makes a report under this paragraph must
give the senior coroner a written response to it.
(3) A copy of a report under this paragraph, and of the response to it, must be sent
to the Chief Coroner
INVESTIGATION and INQUEST
Ons" May 2012 | commenced an investigation into the death of Anmad Doumani Khan
(aged 20 years). The investigation concluded at the end of the inquest on 21* January
2013. The conclusion of the inquest was that Mr. Khan died from multiple injuries
sustained in a fall from the top level of the Q Park car park, St. Paul's Square, Sheffield.
The narrative conclusion stated that no other person was directly involved in the fall, but
it was aiso not clear if Mr. Khan intended to take his own life.
4 | CIRCUMSTANCES OF THE DEATH
On the morning of the 3" May 2012 Mr. Khan was in Sheffield city centre, with friends.
Mr Khan was known to have probiems, and he sent text messages to persons at that
time. However, he was also indicating plans he had for later that day, and into the
future.
CCTV shows that Mr. Khan and a friend were in the area of the Q Park car park from
1300 hours to 1710 hours on that date. They were seen to walk up through the lift area
of the car park and eventually they went onto the top floor, which is uncovered. There is
no CCTV coverage of the area where Mr. Khan fell from.
Mr. Khan was with his friend when he got on to the perimeter wall, near to a corner of
the car park. A short while later he fell, witnessed both by his friend and a person in a
nearby building. Mr. Khan’s friend indicated that when he, Mr. Khan, was stood on the
perimeter wall, at the corner, Mr. Khan was only about 3 feet above him.
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) Access to the perimeter wall is very easy. There is the height issue (only about 3
feet), but also the fact that inside the wail is a crash/protective barrier for the parking of
cars, which was described by the friend as being used by Mr. Khan as a ‘step’, up on to
the wall. The concern is that any person, of almost any age, and certainly much
younger than Mr. Khan, could quickly and easily gain access to the top of the perimeter,
wall for any purpose. Such access is clearly dangerous.
(6 |
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action.
——_
r7 |
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 28" August 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:
The family of Mr. Khan.
| 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.
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.
‘ a) §
[DATE] Qe fume Dory [SIGNED BY sone
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.
os ee are ee ss Place Directorate gs Sheffield Regeneration & Development Services City Council Howden House - 1 Union Street - Sheffield - S1 2SH Tel: 0114 2734188 Ref: DM/LB/MD/DP Date: 6 May, 2015 Office of H.M. Coroner The Medico-Legal Centre Watery Street Sheffield S3 7ET Dear Sirs Ahmad Khan (deceased) Charles Street Car Park, (Q Park Ltd), 73 Charles Street, Sheffield | refer to the Coroner’s Report in connection with the above case. | apologise for the delayed response in this matter, which is down to an internal logging error. On receipt of the Coroner’s report last year my enforcement team established that there was no breach of planning control at the Q Park facility and that the building is also compliant with the Building Regulations. This means that there is no formal action that we can take in this case. Nevertheless | have written to Q Park Ltd to suggest possible alterations to the building to try and prevent something like this happening again. Officers have also spoken to the Managing Director of Q Park, EEE in a bid to persuade them to take action, although we cannot insist on this. Whilst there is no obligation on the owner's to present a proposal to the Council to better protect the parapet to the top deck of the car park | can confirm that the Planning Service is open to working with the company to achieve a solution to the problem should they chose to do so. Yours faithfully Interim Head of Planning Large print versions of this letter are available by telephoning (0114) 273 4791
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