Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0411, written 19 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2014 |
|---|---|
| Reference | 2014-0411 |
| Deceased | Aaron Plowman |
| Coroner | Lorna Tagliavini |
| Coroner area | London Inner (South) |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. Network Rail Kings Place, 90 York Way, London Ni 9AG 169-189 Clouds Rest Road Soulsbyville, CA 95372 USA 4 | CORONER | am Lorna Tagliavini assistant coroner, for the coroner area of Inner London South CORONER’S LEGAL POWERS 1 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. INVESTIGATION and INQUEST On 19 March 2014, | commenced an investigation into the death of Aaron Jacob Plowman. The investigation concluded at the end of the inquest on 4" September 2044. The conclusion of the inquest was “Accidental death: and the cause of death (1a) Cerebral Trauma (1b) Deceleration injury 4 | CIRCUMSTANCES OF THE DEATH On 14" March 2014 at around 05.09 hours, the deceased was found to have fallen through a corrugated plastic roof over garage premises onto a concrete floor below. The premises were located at TR Autos a garage located in the railway arches at 111-113 Elephant Road and the j/w New Kent Road, London. 5 | 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 roofs of the commercial units under the railway arches has not been blocked off from persons gaining access by climbing up from the street. (2) Specifically the access point from the Lycamobile kiosk and Sonny Kebab and Chicken shop on the New Kent Road under the railway arches remains viable. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. (1) Ensure that access to the roofs of the commercial units located underneath the railway arches at the Elephant and Castle BR Station at the junction the New Kent Road and Elephant Road is prevented by persons either climbing up or otherwise accessing | and the void spaces between the arches and the commercial units. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7" November 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. NB:If you are not the organisation responsible for this location please provide information identifying the relevant company/individual. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (i) lam 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. 9 | DATE: 19" September 2014 Th BY CORONER: LM Tagliavini
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