Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0055, written 22 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2018 |
|---|---|
| Reference | 2018-0055 |
| Deceased | Christopher Brookes |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Chief Executive, Wolverhampton City Council 2. Transport for West Midlands, West Midlands Combined Authority. 3. West Midlands Fire Service, Black Country North Fire Safety team. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 2 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. 3 INVESTIGATION and INQUEST On the 8 November 2017, I commenced an investigation into the death of Mr Christopher Brookes. The investigation concluded at the end of the inquest on 22 February 2018. The conclusion of the inquest was a short narrative conclusion of: Accident The cause of death was: 1a Cranial Trauma 4 CIRCUMSTANCES OF THE DEATH i) Mr Brookes was a 22 year old gentleman who had been out socialising on the 28 October 2017 celebrating a family birthday. ii) He later made his way to the Wolverhampton bus station and around 2am left the station via a fire exit. iii) It appears from the evidence available he tried to climb over a gate whilst leaving through a fire exit and then fell around 40 feet to the road below. iv) He was taken by ambulance in Birmingham, but sadly died from the injuries sustained on the 29 October 2017. the Queen Elizabeth Hospital to 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 [IL1: PROTECT] 1. Evidence emerged during the inquest that there was a previous incident at the same location involving a member of public who narrowly escaped falling to the road below in April 2017 in similar circumstances. 2. Evidence also emerged during the inquest that an alarm would be activated if the fire exit was used. It appears that security guards employed to deal with unauthorised use of the fire exit failed to attend. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider further reviewing the safety arrangements in place at this location and consider what additional measures can be put into place to try and prevent a reoccurrence. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 April 2018. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. I 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. 9 22 February 2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Cijyor WOLVERH AMPTON Zafar Siddique Senior Coroner Black Country Coroners Court Jack Judge House Halesowen Street Oldbury West Midlands B69 2AJ 26 March 2018 Dear Zafar Christopher Brookes (deceased) - Prevention of Future Deaths Report I write with reference to your Regulation 28. Prevention of Future Deaths Report, dated 22 February 2018. A representative of the Council was present during the course of the Inquest and as such, the Council is aware of the issues and concerns that you have raised. I take the opportunity to respond to your concerns, as set out below. The Council had no knowledge of a previous incident, prior to Mr Brookes’ sad death 1. being notified to the Council. As such, the Council was unaware that there had been a previous incident and has no knowledge as to the circumstances of that incident, whether the incident occurred in similar or entirely different circumstances. As such, the Council was not on notice as to the previous incident occurring. With regard to the alarm being activated, as you may be aware from the evidence 2. given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape aoor from the bus station itself, In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area. With regard to section 6 of your report, I confirm that following Mr Brookes’ sad death, the Council has worked with both the health and safety executive and the fire service, to review the index area, As you may be aware, the Council has no control over the fire escape from Cly of Woierhampten Ccnci IJ\J1 I RL (o’itin ed 0 wolverhampton gov.uk • WolverhamptonToday the bus station itself, as detailed below but the Council is able to make changes to the fire escape route and the gate at the end of that. Changes have already been made. Following the incident occurring, the Council has liaised closely with the fire safety authority. The health and safety executive has confirmed that the height and construction of the fencing along the fire escape route is appropriate and meets the relevant regulations. The gate itself has been inspected and maintained, including the push pad mechanism. As you are aware from the Inquest, there is no locking mechanism of similar placed on the gate at the relevant time. In addition to the above, the Council has installed additional safety lighting on the fire escape route, together with signage, highlighting the existence of a drop below the fire escape route. The Council has also committed to working with the other relevant parties, including the combined authority and the other users of the building, to include Sainsburys supermarket, who occupy and area of the ground floor of the building. I trust the above is of assistance. Should you require any further information, please do not hesitate to contact me. Yours sincerely Managing Director City of Vvoiverhamptor Counc Civc Centre St Peters Square WVI I RL Q woiverhamptongovuk 0 @WolvesCouncN • WolverhamptonToday
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