Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0246, written 30 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jun 2015 |
|---|---|
| Reference | 2015-0246 |
| Deceased | Colette Hughes |
| Coroner | Selena Lynch |
| Coroner area | South London |
| 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.
In the South London Coroners Court Inquest touching the death of Colette Hughes Regulation 28: Report to Prevent Future Deaths THIS REPORT IS BEING SENT TO: Hammerson PLC 1 | CORONER | am Selena Lynch senior coroner for the coroner area of South London 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 On7" July 2014 | commenced an investigation into the death of Colette Hughes (50). The investigation concluded at the end of the inquest on 20" May 2015. The conclusion of the inquest was that she had committed suicide, and that she died of multiple injuries sustained on 7" July 2014 when at about 4.30 p.m. she jumped from the top storey of the multi-storey car park at Centrale Shopping Centre in Croydon. She had been suffering from an undiagnosed psychiatric condition. 4 | CIRCUMSTANCES OF THE DEATH Mrs Hughes spent some time sitting on the flat and wide perimeter wall surrounding the top level of the multi storey car park at Centrale Shopping Centre, before standing on it and jumping to her death. 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. — The wall is easy to access and at least two previous deaths have occurred in similar circumstances since 2006. Whilst recognising that barriers cannot be provided at every location above ground, and the fact that the building complies with regulations , there is a concern that others may die in the same manner. There is also a concern that the wall presents a danger to those who may decide to use it as a seating area, particularly after taking drink or drugs. In the absence of some physical modifications, the notices advising visitors of the services of the Samaritans recently installed may not be sufficient. 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report namely by the 27" August 2015. 1, 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 a of Colette Hughes South London and Maudsley NHS Trust | have also sent it to the Planning and Regeneration Department at Croydon Council and to the Health and Safety Executive who may find it useful or of interest. 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. 30" June 2015 SIGNED BY CORONER
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.
= Hammerson ple hammerson.com
oO Kings Place, 90 York Way, +44 (0}20 7887 1000
= london, N1 9GE
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In the South London Coroner's Court CEIVED
Inquest touching the death of COLETTE HUGHES
Regulation 28 : Report to Prevent Future Deaths
RESPONSE OF HAMMERSON PLC
1.
Following the conclusion of the Inquest into the death of Colette Hughes, and
pursuant to the provisions of the Coroners and Justice Act 2009, Schedule 5,
Paragraph 7 and the Coroners {investigations} Regulations 2013, Regulations 28
and 29, the Senior Coroner issued a Report to Prevent Future Deaths to
Hammerson ple dated 30' June 2015.
This is the response to that Report on behalf of Hammerson ple.
In relation to the top level of the Centrale public car park we have identified the
following measures that can be taken in response to the concerns of the Senior
Coroner:-
3.1. We are making access to the parapet walls to the corner of the car park
from which Colette Hughes fell (Level 3) more difficult with ‘hostile planting’
being introduced which in particular will assist in preventing access. For an
example of how hostile planting is introduced see Appendix A
3.2. Generally to prevent the lower (less than 1.8m) level walls on levels 3 and 3A
(rooftop level) which are under 1.8m in height potentially being used by
members of the public to lever themselves up onto the perimeter ledge, we
are installing similar hostile planting which will prevent access in those areas
where the potential fall distance is over 5 metres i.e. beyond the next car
park level.
3.3. IN order to prevent cars from parking close to any lower level parapet walls
we are installing vehicle stopping barriers along the floor adjacent to the
walls in the relevant locations. This will prevent cars being used as a step up
to a perimeter wall by members of the public (Appendix A).
Hammerson plc hammerson.com
Kings Place, 90 York Way, +44 (0)20 7887 1000
London, Nt 9GE
uosJOWILUDY
4, These measures will be completed by 30'" September 2015.
5. Following receipt of the Report we commissioned structural engineers to advise
on the feasibility of raising the height of the parapet walls on levels 3 and 3A.
Their report (received on 14'” August 2015) in summary advised how this could be
achieved but would involve regulatory planning and building regulations
approval. This is currently being explored.
6. The measures set out in paragraph 3 have been submitted to the enforcing
authority for health and safety at the Borough of Croydon who will be revisiting
the Centre at the end of September 2015.
for and on behalf of Hammerson plc
20" August 2015
Appendix A
Key = fixed vehicle stops
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