Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0083, written 19 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2018 |
|---|---|
| Reference | 2018-0083 |
| Deceased | Kellie Taylor |
| Coroner | Paul Marks |
| Coroner area | East Riding and Kingston-upon-Hull |
| Category | Suicide (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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 P| Head of Operations, Humber Bridge Board, Ferriby Road, Hessle, East Yorkshire HU13 0JG 1. | CORONER lam Professor Paul MARKS BA LLM MD FRCS, Senior Coroner for the coroner area of East Riding and Kingston upon Hull 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made 3. | INVESTIGATION and INQUEST On 7" September 2017, I commenced an investigation into the death of Kellie Marie TAYLOR formerly known as Kellie Marie DANVILLE. The investigation concluded at the end of the inquest on the 5" of March 2018. The conclusion of the inquest was SUICIDE. Kellie Marie TAYLOR formerly known Kellie Marie DANVILLE was pronounced deceased within the Humber Rescue Boathouse Hessle Foreshore, Hessle on the 4" September 2017. The cause of her death was due to massive intra-abdominal haemorrhage, consequent to traumatic splenic rupture which ensued as a result of a fall from height. 4. | CIRCUMSTANCES OF THE DEATH She jumped from the Humber Bridge into the river below and died as a result of Ia) Massive intra-abdominal haemorrhage Ib) Splenic rupture Ic) Fall from height ID) Lung contusions with haemorrhage 5. | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. Evidence was heard that the close circuit television monitoring system on the bridge was of poor quality and this has been known for some time. The significance of this is that the precise sequence of events of Kellie leaving the car from which she was travelling in to her getting to the parapet of the bridge was not accurately visulaised due to the poor resolution of the system. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Lam concerned that if other individuals go to the bridge with the intention of jumping off or any other emergency were to occur, the quality of the TV system as it is now is such that their behaviour or activities cannot be accurately seen by those monitoring the system and as a consequence, intervention may not be provided in a timely fashion. I am therefore writing to you pursuant to my powers under Regulation 28 (Prevention of Future Deaths) to inquire as to what you intend to do with regard to improving the resolution and quality of the CCTV images. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a statutory obligation to respond to this report within 56 days of the date of this notice/report and I, the coroner, may extend the period but you must inform me in writing if you require further time. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Mr Derek Winter, HM Senior Coroner, Coroners Court & Office, Civic Centre, Burdon Road, Sunderland SR2 7DB who may find it useful or of interest. 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. [DATE] 19 March 2018 Fe 7 z [SIGNED] / ee, Professor Paul MARKS C HM Senior 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.
HUMBER BRIDGE BOARD TELEPHONE: (01482) 647161 FERRIBY ROAD FAX: (01482) 640838 _—_" HESSLE EMAIL: mail@humberbridge.co.uk | EAST YORKSHIRE HU13 OJG INTERNET: www.humberbridge.co.uk 10 May 2018 Her Majesty’s Senior Coroner The Coroner’s Court and Office The Guildhall Alfred Gelder Street 11 MAY Hull 2018 HU1 2AA Dear Professor Marks Inquest touching upon the death of Kellie Marie TAYLOR formerly known as Kellie Marie DANVILLE This is the response on behalf of the Humber Bridge Board (“the Board”) in respect of the Regulation 28 Report to Prevent Future Deaths dated 20 March 2018 concerning the above. It is noted by the Board that your concern relates to the quality of the current CCTV system on the Bridge which you believe may have had an adverse impact on the ability of the Board’s staff to monitor and intervene in a timely fashion to an individual who may be considering taking their own life. CCTV can be helpful in enabling our staff to locate and identify, to use the Humberside Police terminology, Emotionally Distressed Individuals (EmDIs) on the Bridge. However, there is no substitute for human intervention, especially in darkness and adverse weather conditions, when CCTV has severe limitations. The Board takes the issue of EmDls at the Bridge very seriously indeed and has taken a wide range of measures to protect people at the Bridge, working very closely with the appropriate partners. The Board has purchased two Impact Protection Vehicles (IPVs) which allows Humberside Police and the Board’s staff to quickly deploy to the scene, even mid-span, and with co-ordination via the Bridge Control office, allow them to stop safely in the carriageway protected from traffic by the IPV. This has already improved response times without impacting the safety of all other Bridge users, the Police or Board staff responding to an EmDI. The Board have liaised with the Samaritans in placing a number of signs, the contents of which have been approved by the Samaritans, out on the footpaths at key locations. The Board is working closely with Humberside Police, and this has resulted in a specialist joint training programme for both Police Officers and Board staff who are deployed to interact with any EmDI. The training includes the appropriate language and behaviour to use when dealing with someone who appears to be emotionally distressed on the Bridge, and also includes how to use the safety harnesses which have been acquired for use by Humberside Police and the Board’s staff. Our Control Room staff have also received training to ensure that they are pro-active in recognising “tell tale” signs of persons entering the Bridge from the footpaths at either end, and deploy staff on to the Bridge to supervise the person if they are concerned or believe they may be an EmDI. We continually seek to make improvements with regard to our approach to the issue of EmDIs who come to the Bridge. We have been invited to join the Hull & East Riding Multi Agency Suicide Prevention Group. This is co-ordinated by Public Health Hull City Council and Public Health East Riding of Yorkshire Council. Group Members include:- Probation Service, HEY MIND, Humber NHS, Humberside Fire & Rescue Service, NHS Goole CCG, Humberside Police, NHS ER CCG and the Samaritans (Hull & East Riding). We have also been consulted on the draft East Riding Suicide Prevention Plan, 2017-20, which makes reference to prevention plans at the Humber Bridge. | attended the meeting of the group at East Riding Council Offices in Beverley on 23 February. The meeting thanked the Humber Bridge for all that we have done to improve our approach as regards this issue over the past 12 months. | hope that this response provides you with the reassurance that you are seeking that the Board are undertaking all reasonable actions with regards this matter. Yours sincerely RP tlloore Dr Kevin Moore Chief Executive Humber Bridge Board
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