Prevention of Future Deaths reports · 2018

Jordan Sheils

Regulation 28 report to prevent future deaths, reference 2018-0319, written 16 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Oct 2018
Reference2018-0319
DeceasedJordan Sheils
CoronerMartin Fleming
Coroner areaWest Yorkshire (West)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

INTHE WEST YORKSHIRE WESTERN CORONER’S COURT

IN THE MATTER OF; .
The Inquests Touching the Death of Jordan Ryan Sheils
A Regulation Report - Action to Prevent Future Deaths

[| THIS REPORT IS BEING SENT TO:

| _| Borough Council

Chief Executive - Calderdale Metropolitan Borough Council oe Tf
Highway Asset Manager - Calderdale Metropolitan

L

CORONER =),
Martin Fleming HM Senior Coroner for West Yorkshire Western ~

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 7

| Econcluded with a narrative conclusion of Suicide

INVESTIGATION and INQUEST .

On 7/4/17 I opened an inquest into the death of Jordan Ryan Sheils who,
at the date of his death was aged 19 years old. The inquest was resumed
and concluded on 15/10/18 ,

I found that the cause of death to be: -

la. Multipleinjuries © _ .

L

CIRCUMSTANCES OF THE DEATH onl
On the evening of 3/4/17 Jordan went missing from his father’s home
address. Thereafter mother, father and girlfriend received several
worrying text messages from him between 10.35pm and 11.02pm,
prompting his sister to report him missing to the police at 11.13pm and
urgent attempts to locate him were made. Subsequently the next day of
4/4/17 at approximately 3.23pm, Jordan’s body was found by a passing
witness immediately beneath the North Bridge. Upon the arrival of the
police he was recovered face down in the water and was found to have
passed away. The pathologist found that he had sustained multiple
injuries internal injuries consistent with a fall from a great height. It was |
found that he had jumped from the bridge with the intention of taking
his own life and that third party involvement can be excluded.’

RT3589__. 1

CORONER’S CONCERNS -- sees —
During the inquest I Pole very helpful oe from a
Highway Asset Manager, who told me that the council are currently in
the process of considering of obtaining planning permission for anti-
climbing mesh at the location, although it is: not thought it will be
implemented until early next year.

The MATTER OF CONCERN is as follows. —

. © To review the existing measures for deterring such tragedies with
a view to expediting their introduction particularly with regard to

hae that the Chief Executive has the power to take such action.

prominently displayed CCTV cameras overlooking the bridge.
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I

r

—

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 thé timetable for such action. Otherwise you must
explain why no action is proposed.

COPIES 7 7 |

Ihave sent a copy of this report to:

BE other

- Father

Chief Coroner

DATED this 16/10/18 " Senior Coroner - West Yorkshire - Western Division

—

RI3589 2

Responses

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.

Response from Calderdale Council (PDF)
Regulation 28 Report to Prevent Further Deat
This response Is being sent to: = 7 7
Mr M.D. Fleming Senior Coroner, West Yorkshire (Western District), City Courts, The Tyrls, Bradford, BD1
1LA. a
In response to a Regulation 28 Report to Prevent Further Deaths following an inquest hearing into the
death of Jordan Ryan Sheils at North Bridge Halifax that concluded on 15" October 2018.
1. Calderdale Council a
lam Mr EE ghway ‘Asset Manager, Calderdale Council, Ainley’s Depot, Huddersfield Road,
Elland, HX5 9JR,
2. Coroners Matter of Concern
The Matters of Concem were identified as;

2.1 To review existing measures for deterring such tragedies with a view to expediting their
introduction particularly with regard to prominently displayed CCTV cameras overlooking the ©
bridge ,
3. Action Taken

3.1 To review existing measures for deterring such tragedies with a view to expediting their
introduction particularly with regard to prominently displayed CCTV cameras overlooking the
bridge

3.2 A report was submitted to Calderdale Council’s Cabinet on 30" July 2018 outlining 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.

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 coping) is submitted to the Local Planning Authority;

° That finance required, currently estimated at £200,000, be made available from
budgets as appropriate.

3.3 A Planning and Listed Building Consent application was submitted on the 5"" October 2018, upon
approval the works will be tendered and is currently pending approval.

33 Provision of CCTV camera

An additional CCTV camera was installed on the 23 November 2018 to provide coverage of
North Bridge.

3.4 Provision of Temporary Heras Fencing

Any temporary fencing would be free standing and not prevent an individual from gaining access
to the existing parapet, this option is therefore not considered suitable at this location.

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4. Timetable for Implementation

Action .

Timescale ;

Comments

Feasibility Study ~

Review of CCTV coverage

Feb 18 to July 18

Feb 18—July 18 °

Complete

- Completed

Approval By Cabinet

30-7-18

Complete

Finalise Drawings

Temporary Fencing Review

Feasibility study for installation

of additional CCTV,

Aug 2018

‘Sept 2018

Aug 2018 —Sept 2018 -

Completed

Completed

Ongoing

Listed Building Consent

installation of CCTV Camera

5 Calderdale Suicide Prevention Group

5.1

5.2

5.3

5.4

Contract Preparation
Tender Period
Site Works _

Works Complete

-Oct 18-Dec 18

Submitted 5” Oct 2018.
Pending approval.

Nov 2018

Installed .

Oct 18-Nov18 .
Jan 18 to Feb 18
Mar19 to May 19

31-May-19

. Ongoing

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.

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:

behaviour

e support research, data collection and monitoring

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

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 plan to
undertake a follow-up suicide audit in January 2019.

The proposed works at North Bridge have been discussed and agreed with our Public Health
colleagues who lead the Suicide Prevention Group.

‘

6 Copies

6.1 trespectfully.ask that a copy of my response be forwarded to the interested Persons to the —
inquest and your regulation 28 report dated 16" October 2018 and the Calderdale Suicide
Prevention Group. ;

Dated: 11 December 2018

Signed: ;
Richard Mills Highway Asset Manager, .

Calderdale Council

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