Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0379, written 19 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Oct 2015 |
|---|---|
| Reference | 2015-0379 |
| Deceased | Kyle Hull |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| Category | Other related deaths · Child Death (from 2015) |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HERE Dariington cattle Mart, Clifton Road, Darlington DL1 5DU CORONER | am Andrew Tweddle Senior Coroner, for the Coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 20" April 2015 | commenced an investigation into the death of Kyle David Michael Hull, aged 15 years. The investigation concluded at the end of the inquest on 16' October 2015. The conclusion of the inquest was accident. CIRCUMSTANCES OF THE DEATH The deceased was a teenager who suffered fatal injuries after falling through a fragile roof at the Auction Mart. The risks of people falling through the Auction Mart roofs were well known. Children have been known to play on the roofs. A Health and Safety review has been undertaken following the incident and certain remedial steps taken. 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. — Evidence was given about limited CCTV coverage and access thereto via a Council system. This may not be adequate and consideration ought to be given as to whether a more extensive CCTV installation and monitoring thereof may be able to alert the Company and/or others to potential risks of people harming themselves and/or damaging the property and early intervention might be helpful and further, such CCTV may be able to better identify particularly high risk areas, especially dangerous and fragile roofs. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" December 2015. I, 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 Pe and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18). | 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. SIGNED H M Senior Coroner County Durham and Darlington Datted..........cstecsteccsecedeDooveessesseseessessssecserees
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.
14 DEC 2015 THE DARLINGTON FARMERS AUCTION MART COMPANY LIMITED Registered Office: Bank Top Mart, Clifton Road, Darlington Co. Durham DL1 5DU. Tel: (01325) 464529. Fax: (01325) 384282 1st December 2015 Dear Mr Tweddle LL.B Re: Regulation 28 Report to prevent future deaths. In reply to your letter dated 19 October 2015. Darlington Auction Mart Co Ltd believe that the measures in place before the tragic loss of life of Kyle Hull were enough to make persons entering the Darlington Mart premises at Clifton road aware that the area is a working environment and that any person attempting to gain access to any of the roof areas of any building were doing so at their own risk. The premises after the tragic event on the 7‘ of April 2015 were visited by Police, HSE and our insurance firm, they were all satisfied with the levels of signage and the systems in place to secure the site. However, we as a company will do what is believed to be correct and in the interests of the inquest, the family of Kyle Hull, local individuals that have raised concern and to deter other persons from entering the grounds. Since the inquest we have had two CCTV firms out to measure the site, both have taken time in what type of CCTV would be needed, the number of CCTV’s, maximising the area of coverage as the design of the mart makes it extremely hard to cover every corner. The conclusion was that CCTV’s with night vision, movement detection and linkage to the internet where the images can be streamed to Mobile phones of company management. This system above does involve a lot of civil works and cabling within the grounds also a full upgrade of the computer systems within the office to enable this to run correctly. Our software programs provider has quoted £6000 Registered in England No. 212585 The quotations that have been received are currently within the region of £15,000 to £20,000, with yearly maintenance and service charges. The situation is that we are currently looking to finance this level of expenditure. The conclusion to this issue will have a final decision by the 18 of December at the last yearly board meeting of the company. I look forward to hearing you reply Mr Tweddle, we as acompany and I asa company director and representative are supportive to the issues you raised. Yours Sincerely Ai
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