Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0106, written 17 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Mar 2015 |
|---|---|
| Reference | 2015-0106 |
| Deceased | Alasdair Penny |
| Coroner | Michael Burgess |
| Coroner area | West Sussex |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
‘ REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways department of West Sussex County Council 2. Chief Constable of Sussex Police 1 | CORONER | am Michael Burgess, assistant coroner, for the coroner area of West Sussex 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. 3. | INVESTIGATION and INQUEST On 7 May 2014 an investigation into the death of Alasdair Neal PENNY aged 23 was commenced. The investigation concluded at the end of the inquest on 17 March 2015. The conclusion of the inquest (as found by the jury) was Name of Deceased: Alasdair Neal Penny Medical Cause of Death: 1(a) Multiple injuries Circumstances and How, when and where the death came about: Unable to determine his intention 4" May 2014 Underneath Beeching Bridge, A22, East Grinstead, West Sussex Conclusion of the inquest: Alasdair Penny Jumped from the College Lane Bridge, East Grinstead onto the A22 but the evidence does not fully disclose what his intention was. 4 | CIRCUMSTANCES OF THE DEATH This case concerned a 23 year old man who on Sunday 4 May 2014 jumped from a road bridge onto the road below. It had been the site of a similar suicide 3 years before (Will RAYNOR - in fact the 3 anniversary was a couple of days before this incident) and there were floral tributes to be found there and friends of the previous case had gone there. The deceased was suffering from Paranoid Schizophrenia and had various difficulties with his family, as well as a pending court case. He was refusing to take medication. In the 2 days before his death he was seen by several people loitering on the bridge. At different times, police units attended and questioned him but none found him in a condition that warranted using their s.136 Mental Health Act 1983 powers. Eventually on 4 May 2014 he jumped just as a further police car approached (in a non-threatening way —i.e., no blue lights or sirens). There was evidence from the Healthcare professionals as well as various police officers. 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. — This Bridge has been the site of 2 suicides in 2011 and 2014; | am unaware if there have been any other successful suicides at this location before then, but if so, not in the very recent past. In each of the 2 cases the deceased jumped from the bridge on to the road below, a distance of 10-11 metres. The 2 footpaths that bound the carriageway each have a metal railing and the height of the railing is such that they can be quite easily mounted. There is a series of discrete notices on the mesh infill to the railings, giving details, | understand, of the Samaritans $ | cannot, and do not, offer a solution | certainly recognise that merely raining the level of the railing may not prevent the determined person to climb up and jump. But it might well stop the spontaneous jumper. | understand that | do not know whether it is possible/feasible to provide extra/or some other form of protection in order to make it more difficult for the bridge to be used as a suicide site. However, | do believe that the whole situation should be reconsidered in case something can be reasonably implemented to minimise the possibility of a recurrence. In my opinion action should be taken to prevent future deaths and | believe you pr 6 | ACTION SHOULD BE TAKEN AND/OR your organisations have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 May 2015. |, 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the solicitors for the following Interested Persons HS (Parents), The Sussex NHS Partnership Trust and The Chief Constable. 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. 17 March 2015 Ube cf— M.J.C. BURGESS - ASSISTANT CORONER
2 responses 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.
[\feARawerR 13 MAY 015 | Giles York Our Ref: CC/GY/VLF 8" May 2015 Michael Burgess Assistant Coroner for West Sussex Coroner’s Office West Sussex Record Office Orchard Street Chichester West Sussex PO19 1DD Dear Sir, Re: Inquest into the death of Alasdair Neal PENNY — 16" and 17" March 2015-05-08 | write in response to your formal report under Regulation 28: Report to Prevent Future Deaths. The concern around the bridge was raised in 2013 through the East Grinstead Neighbourhood Joint Action Group (NJAG). This was following the suicide of William Rayner in February 2011 and a further incident in which a member of the public was pulled back from the wrong side of the bridge in June 2013. The group consisted of representatives from the local police team, town council and West Sussex County Council (WSCC). Over the period between June 2013 and the suicide of Alasdair Penny, numerous recommendations were made by the NJAG which included - - Raising the parapets of the bridge. - Consideration of a designated zone for memorial flowers. - Cut back the vegetation on the banks to reveal the true nature of the drop. - Implementation of signposting for Samaritans etc on the bridge. - No stopping on Bridge signs. - Patrol activity from the local EG Street Pastors. - Continued Police patrols of the area. ... cont/d Police Headquarters Malling House Church Lane Lewes East Sussex BN7 2DZ Telephone 101 Fax (01273) 404263 Website: http://www.sussex.police.uk e-mail: chief.constable@sussex.pnn.police.uk The NJAG group was able to implement 6 Samaritans signs on the bridge which are still currently in place and the Street Pastors continue to patrol the bridge, as do the local police team. The raising of the parapets, which was the partners preferred recommendation, was referred to WSCC and was discussed at the County Local Committee meeting in late 2014. WSCC reported that the vegetation could not be cut back and a report was being prepared as to the reasons why. The potential alterations to the bridge are being managed by WSCC and an update meeting is planned between Peter Lawrence (WSCC), Julie Holden (EGTC) and PS Graeme Prentice (Sussex Police) on the 20th May 2015. Yours sincerely, Chief Constable
County Hall ig no? Director of Highways and Transport West Street pate west Chichester Ch West Sussex moins Highways Contact Centre Telephone: 01243 642105 POLS 1RQ coun y www.westsussex.gov.uk coOuNCI 11 May 2015 Private and Confidential Penelope A Schofield Coroner's Office West Sussex Record Office Orchard Street Stee Re ee eerie _ Chichester West Sussex. PO19 1DD Dear Madam Respon f W. Ss nty Council he regulation 2 ‘O Prevent Future Deaths issued by M J C Burgess, Assistant Coroner dated arc 5 ° ga quest into the death of Alasdair Neal 17 March 2015 followin n_ingu Penny. I am writing with regard to the actions we Propose to take following receipt of your report into the death of Mr Alasdair Neil Penny as a result of a fall from the College Lane Bridge, East Grinstead. I was very sorry to read of the events that led to the death of Mr Penny and wish to extend my sympathies to his family. I understand Mr Penny was suffering from Paranoid Schizophrenia, but was refusing to take his medication. In the days leading up to his death he had been seen at the bridge on a number of occasions, where his odd behaviour led members of the public to report him to the police. On the day before his death he was picked up by the police from the bridge and returned to his parents’ home address, though checks made then did not reveal his mental health problems. You raise the following two matters of concern. * The bridge has been the site of a previous suicide in 2011 ¢ The height of the railings at the back edge of the footways that bound the bridge is such that they can be quite easily mounted and would not deter a spontaneous jumper. The bridge was the location of a previous suicide in 2011. It is very likely Mr Penny knew Mr Raynor. They had both attended the same secondary school, possibly in the same year group. We are not aware of any other similar events prior to Mr Raynor’s death in 2011 The College Lane road bridge was constructed to modern design standards, with 1m high parapets conforming to BS6779 part 1 Highway Parapets for Bridges and other Structures. This is the national standard and is applied across the whole of West Sussex for road bridges carrying a carriageway and adjacent footways. However, we understand your concerns that this standard height is unlikely to inhibit a deliberate action to climb over the parapet and jump from the bridge. While we would caution that it is unlikely that any engineering solution would be 100% effective we will be investigating whether it is technically feasible to increase the height of the current parapet to deter as far as practicable similar events occurring in the future. If an appropriate solution can be determined we intended to undertake the alterations within this financial year, subject to any design and programming constraints. If an appropriate technical solution cannot be realised I will write to you again explaining the reasons why. We will also be raising the issue with other partners through the East Grinstead Neighbourhood Joint Action Group (NJAG) to see if there is any further appropriate preventative work that can be _ initiated from a community perspective including the potential of additional work with vulnerable young people through our Health Services. Previously the East Grinstead NJAG was responsible for arranging the current Samaritans signs and for organising for the local Street Pastors to make the bridge part of their regular patrols. Yours sincerely Director a a and Transport
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