Stephen Lawson

BEDFORD BOROUGH COUNCIL §

Borough Charter granted i in 7 166

y S
49 INVESTOR {N PEOPLE

ef Executive: P. J. Simpkins

Your Ref:
Mr | Pears Our Ref: CEX/E4 [054 je]
Acting Senior Coroner Contact:
Bedfordshire & Luton Direct Dial:
HM Coroners Office » Fax:
The Court House Email:
Woburn Street, Ampthill
Bedfordshire MK45 2HX 3 October 2018

Dear Mr Pears

Re: Inquest touching the death of Stephen James Lawson

| write further to your letter dated 13 August 2018 in connection to the unfortunate
death of the above named individual, which references the Regulation 28 Report you
issued in your role as Acting Senior Coroner for Bedfordshire & Luton. | understand
from the Regulation 28 Report that you have commenced an Investigation and have
not yet concluded the Inquest.

Background

The Council owns a variety of car parks for use by residents and visitors to Bedford
Borough, they are provided at convenient locations for work-place parking or
somewhere to park whilst shopping in Bedford town centre. The car parks comprise
of a mixture of multi-storey car parks (MSCPs) and open surface car parks.

The Council is fully aware of its responsibility as the owner of four MSCPs within
Bedford town, and the Council takes its role seriously as a provider of car parking
services to users of its premises. Staff from the Parking Services Team regularly
carry out building/workplace inspection of all MSCPs that are controlled by the
Council. This involves the regular assessment of the physical structure and fabric of
the buildings, along with the assessment of hazards and risks that would be relevant
to the health and safety of those parking and accessing vehicles in MSCPs. As
such, the Council has a comprehensive approach concerning safety, security and
risk management in relation to managing the MSCPs that are under its control.

Please note that.all levels of all MSCPs are proactively patrolled on an hourly basis
by Civil Enforcement Officers (CEOs), part of their remit is to visually assess the
areas and take action regarding unauthorised access or activities that may be taking
place; part of this visual assessment includes taking action and raising the alarm
where a member of the public may be behaving in a manner which gives cause for
concern.

Philip Simpkins Chief Executive
_Borough Hall, Cauldwell Street, Bedford MK42 SAP DX 117105 Bedford 4 —

Phone. (01234) 718202 Fax (01234) 718201 ence
Web www.bedford.gov.uk Minicom (01234) 221827

On the rare occasion that the alarm is raised regarding the behaviour of a member of
the public, there is a comprehensive MSCP Emergency Procedure that CEOs,
Control Room staff and Manager/Team Leaders follow regarding the Council's
response to dealing with the situation. The procedure covers the main actions that
must be carried out where a situation exists that requires an ‘emergency response’,
this includes calling the blue light services (Police, Fire, Ambulance), the closure of
the building, the management of the area and communication with other users of the
building.

Part of the management arrangements of the MSCPs within the Borough ensures
that all levels/decks of the MSCPs are covered by a comprehensive CCTV
surveillance system. CCTV is proactively used to monitor the locations for a range
of issues that might be relevant, one of which being early sighting and raising the
alarm regarding members of the public who behave in a concerning manner near to
the perimeter walls of the car park.

Historically the Council has invested in the safety and security of its MSCPs adopting
a reasonable and risk based approach, utilising competent professionals and
contractors to improve the facilities on offer. Examples of the risk based approach
adopted and the measures implemented as a result can be seen at Appendix B,
Images 3 to 8.

The Council also undertakes regular annual investment regarding the provision of
car parking facilities within the town centre. Periodically the Council also invests in
various capital investment schemes to improve and upgrade the facilities on offer;
these improvements often relate to safety and security of the car parks in order to
provide a well-managed environment for visitors to use.

Recent examples include a full refurbishment of Allhallows MSCP. The work
included new lifts, improved CCTV across all areas of the car park, updated
communication systems, upgraded lighting and fire control systems. This work took
place in 2015 and won an award from the British Parking Association as the Best
Car Park Refurbishment in 2015.

In addition to this last year all the MSCPs received additional CCTV cameras on the
parking levels and in the stairwells, new reactive lighting was installed throughout all
MSCPs and new lifts were installed at Lurke Street Car Park. As stated earlier
CEOs routinely inspect the car parks and at least once an hour. All New recruits
receive a Level 2 City & Guilds training in Parking Enforcement.

As a consequence Bedford Borough Council's MSCPs have held in excess of five
years the British Parking Associations ‘Park Mark’ which recognises quality and
safety within its car parks, in addition to this for the last two years the MSCPs have
also held the ‘Disability Park’ award.

Regulation 28 Report

In reference to section 5 of your report, Coroner’s Concerns, the situation(s) you
refer to have been reviewed by officers of the Council and | am now in a position to
address each point in turn and provide further narrative on the issue. In addition to

my substantive responses below | have also included an Action Plan regarding the
key points identified from your report so that the Council is able to consider all issues
arising from this unfortunate incident (see Appendix A).

| have also provided relevant information in Appendix B regarding your Report
which | trust you will consider useful.

1) This is not the first person to have jumped from this car park
According to emergency calls for the previous five years, a summary of incidents

relating to potential suicides in what can be complex circumstances has been
provided below.

MSCP___| Date _| Brief Description a

Lurke Street | Feb 2015 | Male threatened to jump, police negotiators attended
Jan 2017 | Female threatened to jump, talked down by friend and
presented at hospital, Crisis Team involved

May Male and friend presented at hospital voluntarily after
2017 friend talked down male

May Male threatened to jump, police attended and male
2017 diagnosed/sectioned with mental health needs

Jan 2018 | Male threatened to jump, talked down by police and
attended hospital, Crisis Team involved

Jan 2018 | Male threatened to jump, police attended and male
diagnosed/sectioned with mental health needs

River Street - No Reports
Queen Jan 2018 | Intoxicated male threatened to jump, talked down by
Street CEOs, police took to male mental health team at
hospital
Althallows May Intoxicated male threatened to jump, talked down by
2014 police negotiator, police took to male hospital for

mental health assessment

July 2016 | Female threatened to jump, police officers talked her
down

Jan 2017 | Male threatened to jump, police officers attended and
intervened

2) It is surprisingly easy to gain access to the external barrier wall

The external barrier wall/perimeter wall on each deck of Lurke Street MSCP is
flanked by a steel crash barrier and steel caging (see Appendix B, Image 1 and 2).
This steel crash barrier and caging arrangement serves a dual purpose of protecting
the structural integrity of the perimeter walls of the car park from damage that may
be caused by vehicular collision and restricting the proximity that pedestrians are
able to gain to the perimeter wall of each deck.

The original design of each deck of Lurke Street MSCP includes a ‘reveal’ along
sections of the perimeter walls (see Appendix B, Image 2). This reveal is likely to
have been designed as an architectural feature of the building which increased

visibility/ight onto each deck of the building, whose walls are constructed from pre-
cast concrete.

At the highest point the perimeter walls measure 1450mm in height. At their lowest
point, within the reveal of the section of wall, the perimeter walls measure 950mm in
height. The height of the steel caging is 1150mm at all points of the perimeter wall
and thus exceeds the height of the wall along the length of the reveals.

Save in a construction context, there are no prescriptive dimensions provided for the
height of guard rails, however they should be of sufficient dimension to ensure a
person cannot fall through or over them. In the absence of any standards, HSE
operational guidance suggests that guard rail heights in non-construction context
should be a minimum of 950mm, and goes on to say that a wall could be considered
as a guard rail. Any protection below this height should be justified on the basis of a
risk assessment. For buildings, factories, warehouses, offices, public buildings, retail
premises etc, sufficient dimensions for guard rails or similar barriers will be achieved
by complying with the Building Regulations — which require guard rails of a minimum
height of 1100mm, avoiding the use of horizontal rails.

As a result of the recent incident concerning Mr Lawson a visual audit of all MSCPs
was carried out on 31 August 2018. At the time of the audit the condition of the steel
barriers was considered to be in good condition overall, however it was noted in
certain places that damage had occurred at a small number of locations where
protective plates had become loose/missing on the corner junctions of the steel
barriers, any repairs will be addressed as part of planned remedial works (see Action
Point 7 below).

3) Ifa person accesses the space between the crash barrier and the external
wall, the crash barrier can be used as a step to cross the external wall

It would be ergonomically difficult for a person to access the space between the steel
barrier and the perimeter wall on each deck of Lurke Street MSCP as the steel
caging encloses the vehicular crash barrier. However, if a person were so minded to
climb inbetween the perimeter wall and the steel caged barrier, then the structure
might possibly provide a sufficient foothold for a person to raise their body above the
height of the perimeter wall, thereby exposing themselves to the hazard of falling
from height. It would require a determined and physical effort to climb over the
caged barrier and then use it as a foothold.

4) There are very few ‘Samaritans’ signs, and these generally are only visible
if a pedestrian is exiting the car park

There is some signage located within the MSCPs that promote the services of the
Samaritans for persons that may need to use their confidential counselling services.
Nevertheless, | have requested that a full signage audit be carried out as is set out
below.

Generally

As a result of this incident, | have requested officers to carry out actions as detailed
in the Action Plan set out in Appendix A. By way of an explanation of the various
points in that plan:

Action Point 1

in response to the findings of the audit carried out on 31‘ August 2018 | have
instructed that all steel barriers and steel caging arrangements in all car parks are
assessed by a competent professional, and where repairs may be identified these
repairs will be carried out using a risk based approach to any matters that are
identified, focussing on areas and locations that have a higher use, access/egress
etc. Given the open nature of these buildings there is an element of wear and tear
that is addressed as and when required. It is envisaged that any works identified will
be completed within three months of the date of this letter.

Action Point 2

| have also instructed that each of the four MSCPs is risk assessed as part of the
annual premises/workplace inspection process employed by the Council as part of
its ongoing legal duties. These premises/workplace risk assessments will be
completed by 31 October 2018.

Action Point 3

The MSCP Emergency Procedure will be reviewed and all relevant staff within
Parking Services receive refresher training and instruction regarding the appropriate
response required should an emergency incident occur. This training and instruction
will be completed with all relevant staff by 31 October 2018.

Action Point 4

| have instructed that a full signage audit is carried out in order review all signage
types within the MSCPs, including Samaritans, in order that the Council can be
confident that it complies with any duties to identify existing hazards, to the users of
the MSCPs. It is anticipated that any works identified will be completed within two
months of the date of this letter.

| trust that this response addresses your points and hope that the information
supplied addresses the matters raised in your report. If you require any further
information then please do not hesitate to get in touch.

Yours sincerely

Pus
Philip Simpkins
Chief Executive