Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0168, written 29 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2018 |
|---|---|
| Reference | 2018-0168 |
| Deceased | George Dyson |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| 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.
IN THE MATTER OF: The Inquests Touching the Death of George Terence Dyson A Regulation Report - Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: Calderdale Council CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western a een CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the coroners and Justice Act 2009 and regulations 28 and 20 of the Coroners (Investigations) Regulations 2013 1 INVESTIGATION and INQUEST On 11 July 2017 I opened an inquest into the death of George Terence Dyson who, at the date of his death was aged 78 years old. The inquest was resumed and concluded on 29% May 2018. I found that the cause of death to be: - la. Multiple injuries 1b Fall After consideration of the evidence I arrived at a conclusion of Suicide 4 | CIRCUMSTANCES OF THE DEATH een 5 | CORONER’S CONCERNS On 3/7/17 George Terence Dyson, who had been diagnosed with Alzheimer’s disease and struggling to come to terms with its diagnosis, sustained fatal injuries after jumping from North Bridge, Halifax, West Yorkshire. He had previously left letters and documentation at his home address indicative of his intentions to take his own life and the evidence suggested that he jumped from a point on the bridge where there had been a previous like tragedy. _ RT3589 1 | The MATTER OF CONCERN is as follows. ~ e Tourgently review and consider the appropriateness of protective safety measures on the bridge in order to prevent further like fatalities. e To urgently consider the implementation of immediate measures ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Calderdale Council has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. COPIES Ihave sent a copy of this report to: BE 2:0ther) Chief Coroner DATED this 29/5/18 Signature AAD Flea, RT3589 2
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.
This response is being sent to: Mr M.D. Fleming Senior Coroner, West Yorkshire (Western District), City Courts, The Tyrls, Bradford, BD1 1LA, In response to a Regulation 28 Report to Prevent Further Deaths following an inquest hearing into the death of George Terence at North Bridge Halifax that concluded on 29 May 2018. 1. Calderdale Council . lam Mr Richard Mills Highway Asset Manager, Calderdale Council, Ainley’s Depot, Huddersfield Road, Elland, HX5 9JR. 2. Coroners Matter of Concern The Matters of Concern were identified as; 2.1 To urgently review and consider the appropriateness of protective safety measures on the bridge in order to prevent further like fatalities. 2.2 To urgently consider the implementation of immediate measures. 3. Action Taken 3.1 To urgently review and consider the appropriateness of protective safety measures on the bridge in order.to prevent further like fatalities 3.2 Calderdale Council began a feasibility study to identify options to prevent further suicides at North Bridge in February 2018 and was completed in July 2018, This identified 2 possible options: a) The installation of 3.35m high parapets as installed at Valley Road, Scarborough with curvature and end profiles to deter climbing. Unfortunately, the existing parapets are cast iron and there are no as built drawings which show the connection and details. Recent trial holes have failed to provide further __ information and therefore we cannot determine the overall strength at any one point. There is a risk of failure under loading which has meant this option has been disregarded. b) The installation of anti-climb mesh affixed to horizontal rails to cover the cut outs in the Parapet and a steeple coping to cover the castellated top of the existing parapet providing a 1.45m unclimbable parapet (which would comply with current Design Manual for Roads and Bridges standards). A similar methodology was implemented on Hebble Viaduct which carries the A58 over North Bridge as a suicide prevention measure in 2010. Anti-Climb Mesh and Steeple Coping Areport was submitted to Calderdale Council’s Cabinet on 30" July 2018 outlining these options and the following resolutions were passed: That an application for listed building consent and an application for planning permission for the preferred option described at paragraph 5.3 (anti climb mesh and steeple copirig) is submitted to the Local Planning Authority; That finance required, currently estimated at £200,000, be made available from budgets as appropriate. 3.4 To urgently consider the implementation of immediate measures 3.5 It may be possible to use Heras fencing fixed directly to the existing parapet as a temporary measure this fencing is 2.0m high and has anti climb mesh. Further advice will now be obtained Oven Parte Height 2mm Typical Heras Fencing Panel 4. Timetable for implementation Action Timescale Comments Feasibility Study Feb 18 to July 18 Complete Review of CCTV coverage Feb 18 ~ July 18 Completed Approval By Cabinet Complete Finalise Drawings Aug 2018 Ongoing Temporary Fencing Sept 2018 Ongoing Feasibility study for installation of additional CcTv. Listed Building Consent Aug 2018 — Sept 2018 Ongoing Oct 18 -Dec 18 Contract Preparation Oct 18 - Nov 18 Tender Period Jan 18 to Feb 18 Site Works Mar19 to May 19 Works Complete 31-May-19 5 Details of Further Action to be Taken 5.1 Provision of CCTV. 5.2 Identifying potential Suicides from pedestrians via CCTV is difficult due to the fact that the bridge has pedestrian footways along both sides. A review of the feasibility and effectiveness of the CCTV cameras covering the bridge has been undertaken and has identified a blind spot on the bridge which would require an additional camera to be installed. Further work is ongoing to check feasibility of installing additional CCTV. 6 Calderdale Suicide Prevention Group 6.1 A Calderdale wide multi-agency group was established in 2016 following the completion of a Calderdale suicide audit. A target of reducing suicides to zero in Calderdale has been set; more challenging than the national ambition to reduce suicides by 10% by 2020. 6.2 The Government’s Strategy, Preventing Suicide in England 2012 - A Cross-government outcomes Strategy to save lives identifies 6 key areas of action which will reduce suicides. They are: reduce the risk of suicide in key high-risk groups tailor approaches to improve mental health in Specific groups reduce access to the means of suicide provide better information and Support to those bereaved or affected by suicide support the media in delivering sensitive approaches to suicide and suicidal behaviour ° Support research, data collection and monitoring 6.3 Calderdale’s prevention Strategy and action plan is based on these key areas of action. The plan is led by public health and partners regularly undertake reviews and provide updates to the plan. There is widespread agreement to Implement our suicide prevention plan and deliver Prevention initiatives both across the Council and with other partners, e.g. their pian to undertake a follow-up suicide audit in January 2019, 6.4 The proposed works at North Bridge have been discussed and agreed witii our Public Health colleagues who lead the Suicide Prevention Group. 7 Copies 7.1 t respectfully ask that a copy of my response be forwarded to the Interested Persons to the inquest and your regulation 28 report dated 29th May 2018 and the Calderdale Suicide Prevention Group. Dated: 9th August 2018 Signed: HE Highway Asset Manager Calderdale Council
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.