Prevention of Future Deaths report 2014-0356

Invesco

17 September 2014

Mr David C Heming
Senior Coroner for Peterborough
Senior Coroner's Office (Peterborough)

33 Thorpe Road
Peterborough
PE3 6AB

Dear Sirs

Inquest into the Death of Lynn Margaret Graham Gormly
Regulation 28 Report to Prevent a Future Death

We refer to the Regulation 28 Report issued on 30 July 2014 in accordance with Paragraph 7, Schedule 5, of the Coroners
and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in respect of the above
named Deceased. In accordance with the requirement that we provide a response to the Regulation 28 Report by 24
September 2014, we set out our response below.

Concerns raised by HM Coroner

HM Coroner has identified the following concerns which have arisen during the course of his inquiry:

There have been a number of suicides from 2006 onwards, where individuals have taken their own lives
by jumping from Queensgate Car Parks. The current design of the car park is not effective in preventing
jumps and the recent refurbishment of the car parks did not lead to the erection of barriers/increasing the
height of the walls.

The car park at Peterborough City Hospital which was opened in 2010 and is therefore of modern design,
was constructed in such a way as to provide a significant obstacle to jumping as the wall on the top floor is
approximately three metres high. By contrast, the walls at the upper floors of the Queensgate car parks
and other city centre car parks, are at a low level and do not operate as an effective barrier to jumping.

Falls from the car parks have been into areas where the public use pavements and there is clearly a risk
of death to pedestrians also.

There is evidence in the medical notes and records of some of those who have taken their own lives, that
Car parks are seen as a means of effecting death by jumping.

Finally, within the Regulation 28 Report, HM Coroner enclosed a paper by A anc others (BMC Public
Health 2013, 13:214), which concluded that notwithstanding certain limitations of the review undertaken, reducing
access to means through the installation of barriers can be effective in averting suicides at hotspots and does not
lead to substitution effects.

IREEF - Queensgate Peterborough PropCo S.a rl,
société a responsabilité limitée
Registered office: 37 A, Avenue J.F. Kennedy, L-1855

Luxembourg

R.C.S. Luxembourg B 182,611
Share Capital : GBP 12,500.00

Invesco

Background

IREEF - Queensgate Peterborough PropCo S.a rl. (“IREEF”) acquired the centre in January 2014 and since
acquisition have identified that there had been a recent increase in the number of attempted suicides and suicides
at the Queensgate Centre in Peterborough. We therefore instructed Workman LLP, the largest independent
commercial property management and building consultancy firm in the UK, on 20 June 2014, to review and
consider physical alterations to infill/over-clad openings to the car park floors. Workman was instructed to progress
with a full feasibility study to consider options and costs for a number of infill and over-clad solutions. The
feasibility team comprises the following:

Workman LLP — Project Manager / Coordinator
Beyond — Architect / Designer

Sweett Group - Cost Consultant

Nathaniel Litchfield and Partners — Planning Consultant
Centre Management Team - Queensgate

Following the instruction of i aie’ meeting was held with [EN Centre Director,
on 25 June 2014, At that meeting rovided a summary of the key history, in terms of suicide
attempts at the Queensgate Centre. ee 2:0 provided the feasibility team with the research paper
prepared by i ond others (BMC Public Health 2013, 13:214) as referenced above, which was
provided to the team as part of the briefing process.

Proposals

The feasibility team was asked to consider various solutions for the infilling of openings and over-cladding of the
Queensgate Car Parks. The key matters for discussion were:

3.1 Phasing/priorities

It was identified that inevitably, given the scale of the project and in order to ensure the ongoing business
operation of the Centre, the works to infill/over-clad the car parks will need to be undertaken on a phased
basis. It was therefore determined that the work should be undertaken on a priority basis and the following
prioritisation has been agreed:

3.1.1 Priority one works - this includes all parts of the car parks where the level in question is four
storeys and above from ground level. The bus station elevations above second floor level of the
green and red car park, are also considered priority one works, given the higher percentage of
suicides from these areas and the potential number of witnesses.

3.1.2 Priority two works - this includes all parts of the car parks, where the level in question is two and
three storeys above ground level.

Invesco

3.1.3 Priority three works - this includes all parts of the car parks where the level is one storey above
ground level or at ground level.

3.2 Options

Planning

The Architect / Designer, Beyond was asked to consider a number of infill / over-clad options. Beyond
subsequently produced a number of options which were presented at an interim presentation on 18 July 2014
tous as the Landlord. The initial feedback from the presentation was that a web-net system, which is a flexible
Stainless mesh system, with crimps available in a number of different size meshes and with different grade
steel wire, was deemed to be the preferred solution.

Further to the meeting held on 18 July 2014, it was agreed that given a web-net system was the preferred
solution, a small number of samples of the system should be installed. In conjunction with this further
technical literature should be obtained on the product and investigations undertaken into alternative
manufacturers with similar systems.

Arrangements were also made for representatives of the feasibility team to conduct a site visit to a location
where a web-net system was in use in order to assess the suitability of the option and that visit took place on
20 August 2014.

Following that site visit, an updated / final presentation was held on 12 September 2014, where further detail
was provided by Beyond to the Landlord on the web-net system. At that meeting it was agreed in principal that
the preferred option was the infill option of the web-net system,

Nathaniel Lichfield and Partners (NLP) have been appointed to advise on the planning implications of the proposed
work and the works are likely to require building control approval. The works will also fall under the requirements of
the Construction (Design and Management) Regulations 2007 and will be notifiable to the Health & Safety
Executive.

Next Steps & Indicative Timescales

Subject to final approval from the Landlord, the following steps will be taken to progress the scheme:

2014
¢ Consultant team to finalise the design detail
e Sample web-net system to be installed on site
¢ Planning application to be submitted and building control approval to be obtained
¢ — Project tender — we will proceed with inviting tenders for the works
2015

¢ Construction commences

Additional Measures

In addition to the programme of works to be carried out as outlined at paragraph 5 above, we have already
introduced the following interventions in an effort to deter suicide attempts at Queensgate Car Parks:

Invesco

6.1 More than 200 automated cameras have been installed over the last 4 years;
6.2 We have installed PTZ (Pan, Tilt and Zoom) digital cameras in the top level of the car park to detect any
persons acting suspiciously. The cameras have an automated motion sensor and as such when any

movement is detected, they send a digital image to a video wall in the security control room, which is
monitored 24 hours a day, 7 days a week;

6.3 We have upgraded our security control room with the installation of the latest digital CCTV equipment
which is monitored by two security officers who sit in the control room;

6.4 We have installed a red wall sensor which is a light sensor which detects individuals accessing the car
parks;

6.5 Working with the Samaritans and local stakeholder groups including provision of training;

6.5 Research has shown that music can be beneficial in influencing mood and as such we play positive music
in the stairwells as this may assist with anyone acting on impulse and afford us time to detect the
individual before any attempt is made.

We trust that the information provided demonstrates that substantial measures have already been taken to address the
concerns that you have raised and that further measures are in progress.

We also wish to assure you that we are working as expeditiously as possible to address the concerns that you have raised.
Further, the onsite Queensgate team led a Centre Director, will continue to liaise and engage with the
Suicide Implementation Prevention Group to ensure that progress with these works is communicated to the relevant parties.

Finally, please contact [EEE (Asset Manager) should you require any additional on the matters raised in this letter.

Yours faithfully,

igned by
for and on behalf of IREEF - QUEENSGATE PETERBOROUGH PROPCO S.A.R.L.