Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0495, written 12 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2016 |
|---|---|
| Reference | 2016-0495 |
| Deceased | Archie Hall |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Road (Highways Safety) 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: i. Suffolk County Council Highways Department CORONER | am Nigel Parsley Assistant Coroner for the Coroner area of Suffolk Si CORONER’S LEGAL POWERS I 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 the 30th November 2015 | commenced an investigation into the death of Archie James Hall, aged 20. The investigation concluded at the end of the inquest on the 7” April 2016. The conclusion of the inquest was misadventure with the medical cause of death recorded as being 1(a) aortic transection, 1(b) fall from height. CIRCUMSTANCES OF THE DEATH Mr Hall was a student at Lincoln University who found himself overwhelmed by his studies and with the agreement of his family returned to his Ipswich home on the 24" November 2015 Shortly after arriving home Mr Hall unexpectedly left again in the family car. His family were concerned and started to look for him. The car was subsequently found parked at The Strand, Ipswich beneath the Orwell Bridge. Mr Hall was found on the ground beneath the bridge and regrettably efforts to resuscitate him by both family and paramedics who attended the scene were unsuccessful. Mr Hall was pronounced dead at 21:10 hours on Tuesday 24" November 2015. 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 could 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 Orwell Bridge is a well known very high structure in Suffolk that can be easily accessed on foot. There are a number of locations that provide parking within close walking distance. Once on the bridge there is a pedestrian walkway on both sides which allows full access to its entire length. A concrete wall runs the length of the bridge on the river side of each walk way. A vehicle crash barrier separates each walkway from the carriageway. The bridge wall is between waist and low chest height for an adult and is approximately 30-40 cm in width. As such it is easy to straddle for the majority of reasonable fit adults or young persons. This relatively low concrete wall is the only barrier preventing a fall from the bridge. There is nothing in place that would make it either physically difficult or provide a deterrent against climbing onto the bridge wall. Further, the river side of the bridge walls are bare vertical concrete. As such should someone who had straddled the wall subsequently slip, there is nothing on the structure that would provide a hand or foothold allowing them the opportunity to climb back onto the bridge. This is by no means an isolated incident and | am aware that further inquests are to be held shortly in relation to other deaths resulting from falls from Orwell Bridge. 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. Given the issues identified here following this very sad death, | would request that consideration is given to examining the structure described above and seeing what steps can be taken to make it more difficult for the wall to be climbed and for similar tragedies to occur. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 7" of July 2016. |, 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: Mr Hall's family | am also under a duty to send the Chief Coroner a copy of your response. Similarly, you are 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. Mr N Parsley 12-5-16 wl (ehy
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.
£ highways england Mr. Nigel Parsley Assistant Coroner The Coroner's Office 1st Floor, Landmark House 4 Egerton Road Ipswich Suffolk IP1 5PF Highways England Woodlands Manton Lane Bedford MK41 7LW 7 July 2016 Dear Mr. Parsley, inquest into the death of Archie James Hall This letter sets out Highways England’s response to the Regulation 28 Report dated the 12 May 2015 following the tragic death of Archie Hall in November 2015. First and foremost I extend my sincere condolences to the family and friends of Mr Hall and reaffirm my commitment on behalf of Highways England to both take all reasonable measures and to work with other stakeholders and partners to do all we can to prevent such incidents in the future. Background Orwell Bridge opened to traffic in 1982. Recent years have seen a number of suicides and attempted suicides at the location. This prompted Highways England to commission a review possible measures that could be considered to reduce the likelihood of such tragic events in future. The review completed in March 2015 was carried out in consultation with a range of stakeholders. It identified a range of preventative measures taken in and around similar structures and assessed their the likely effectiveness on psychological, socio and economic aspects of incidents. the Orwell Bridge. The report also considered I will return to the appropriateness of possible interventions together with any action we intend to pursue later in my response. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 INVESTORS I N PEOPLE Current Situation Orwell Bridge carries the A14 Trunk Road connecting the Port of Felixstowe with the Midlands and beyond. It measures some 1287 metres long by 24 metres wide and has a total of 18 spans. The bridge piers range from 20 metres to 45 metres in height. The crossing is neither tolled nor permanently manned. The scale and location of the structure makes routine monitoring along its entirety extremely challenging. We have taken a number of measures to mitigate such challenges including the installation of telephones at each end of the bridge. The phones enable distressed individuals to access immediate counselling and emotional support through contact with the Samaritans. We have also installed closed circuit TV cameras covering almost the entire length of bridge. These cameras are accessed by the Police to monitor unusual activity or behaviour. Options and future actions The 2015 review identified that the installation of physical barriers were likely to be one of the most effective means to deter suicides. The parapets fully comply with height requirements designed to prevent pedestrians accidentally falling from the structure. In relation to Orwell Bridge, the review concluded that the use of additional barriers such as solid parapets or panels would add considerable weight to such a long span structure. The addition of such weight when combined with effects of high winds would have a significant impact on the stability of the structure. The review also looked at the possible use of catching nets. Notwithstanding the safety risks of installing and maintaining such nets, the presence of such equipment would hinder effective inspection and maintenance of the structure itself. Access to the bridge is unrestricted. It currently forms part of the Stour and Orwell Walk, which is actively promoted by Suffolk County Council and Suffolk Coast and Heaths Area of Outstanding Natural Beauty. There are laybys situated adjacent to the carriageway on both approaches affording prompt access to anyone attending the bridge by vehicle. We will now consult with stakeholders and other parties regarding access to the bridge to consider what further preventative measures could be taken. We have considered the possible installation of toe holds on the parapets of the bridge. Current design standards expressly state that toe holds should not be provided on the vehicle side of parapets where pedestrian access is possible. No direct reference is made to the outward facing side of such parapets, although British Standard BS 6779-2 states the ‘outer face may be vertical or inclined with plain or featured finish’’. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 INVESTORS IN PEOPLE The installation of toe holds on the outer face of the bridge would create an extended climbing face that could encourage unauthorised access. Their installation would also present a significant health and safety risk to the workforce. We are not aware of the use of such toe holds on the outward facing side of similar structures and therefore their effectiveness in preventing such incidents is unproven. In light of this and the other factors outlined above, we are not intending to take further action in this respect. We are currently reviewing the effectiveness of the telephones located at either end of the bridge. We will implement any changes at the earliest opportunity. * The parapets comply with the requirements of the Design Manual for Roads and Bridges (DMRB). Height which varies between 1.15 metres and 1.24 metres. Current minimum is 1 metre for such parapets as specified in Clause 4.23 of the Design tandard TD19/06 Requirement for Road Restraint Systems). P u b l i c a t i o n We fully understand the wider interest that the circumstances surrounding Archie’s death and possible actions to prevent future such tragedies may create. It will be a matter for yourself and others to determine what, if any, further information is shared more widely given the sensitivity of such issues, particularly when reported in the media. In light of this we fully support the approach taken by a number of related agencies including the Samaritans in discouraging reporting that increases the notoriety of locations such as this. There is no doubt that suicide prevention is a complex and challenging matter. We at Highways England are committed to working alongside others in order to support the multi-agency approach that is required to prevent such tragedies from occurring. Yours sincerely Regional Director Operations Directorate - East Region Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 f V / INVESTORS IN PEOPLE
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