Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0371, written 27 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Aug 2018 |
|---|---|
| Reference | 2018-0371 |
| Deceased | Peter Gledhill |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Other related deaths |
| 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 WEST YORKSHIRE WESTERN CORONER’S COURT IN THE MATTER OF: : Midgehole Working Mens Club The Inquest Touching the Death of Peter Jonathan Gledhill ’ A Regulation Report - Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western 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 INVESTIGATION and INQUEST On 24/8/17 I opened an inquest into the death of Peter Jonathan Gledhill who, at the date of his death was aged 44 years old. The inquest was resumed and concluded on 13/8/18 I found the cause of death to be: - la. Multiple injuries I concluded with a narrative conclusion as follows: On 15 November 2017 Peter Jonathan Gledhill was found face down in Hebden Water, near Lee Mill Road, Hebden Bridge, after he had an unwitnessed fall from a height. Although it is found that he died from the multiple injuries he sustained in the fall and third party involvement can be excluded, the circumstances of the fall and his intentions remain unclear. CIRCUMSTANCES OF THE DEATH On 15/11/18 Peter Jonathan Gledhill at approximately 3.45pm and 4pm sent worrying text messages to his wife. This prompted his wife to make several unsuccessful attempts to re contact him by phone. At approximately 4.30pm Mr Gledhill’s phone was answered by a member of the public walking his dog along the river towards Hardcastle Craggs after finding it on the ground near.to his coat. After providing details of RT3589 1 of the public walking his dog along the river towards Hardcastle Craggs after finding it on the ground near to his coat. After providing details of the location, at Hebden Waters, near Lee Moll Road, Hebden Bridge, the witness then saw that Mr Gledhill had fallen 25 feet down an embankment and was face down in the river. Upon the arrival of police and paramedics to the scene Mr Gledhill was found to have passed away. 5 | CORONER’S CONCERNS The MATTER OF CONCERN is as follows. - e To review safety aspects of the pathway running along the steep embankment overlooking the river and consider the appropriateness of fencing. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the Midgehole Working Mens Club, Halifax has the power to take such action. 7 | 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. 8 | COPIES Thave sent a copy of this report to: 7 e Chief Coroner 9 | DATED this 27/8/18 M.D. Fleming — 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.
we far le a Our Ref: PB/CW251018 ‘ , Your Ref: -| = Please Contact: Website: www.calderdale.gov.uk Email es Telephone: 01422 266156 Date: 25 October 2018 Private & Confidential Mr Martin D Fleming HM Senior Coroner West Yorkshire — Western City Courts The Tyris Bradford BD11LA Dear Mr Fleming re: Pster Jonathan Gledhill, deceased Calderdale Council www.calderdale.gov.uk Public Health 2nd Floor Princess Buildings Princess Street Halifax Xt 1TS Thanks for your letter of 30 August 2018 and the ‘Acuen to PreventihuturesPeaths’ report regarding the above named. You raised as a matter of concer, “to review safety aspects of the pathway running along the steep embankment overlooking the river and consider the appropriateness of fencing”. You further state that you believed that |, as Director of Public Health, have the power to take such action. Although | am an employee of Calderdale MBC | do not have any statutory powers to take action on such issues. Calderdale MBC have a have statutory duty (s.130 Highways Act 1980) to ensure only that the public can enjoy the benefits of the highway. The Council does not own the land and have no legal powers to build a wall or fence, nor have any responsibility to maintain any part of the missing wall. | did ask my Highways colleagues to make some investigations so | could provide you with some additional information. Your report did not identify exactly where the incident occurred but my colleagues have produced a map of the area in question (see appendix 1 attached). The Mountain Rescue Team confirmed that they recovered Mr Gledhill’s body from point A on the map. It is their understanding that his personal effects and shirt were found on top of a wall at point E on the map. My colleagues have also established that the initial section of the track (the section between points B-E on the map) is registered to private individuals and the section of track (E-D on the map) is registered to Midgehole Working Mens Club who own the bowling club. Lee Mill Road between points C -B on the map is not adopted nor is the access track to the Bowling Club between points B-E-D. The footpath running down the access track is shown in pink on the map and this runs for a short distance along the access track to the Bowling Club best company ‘one ta watch £9E2 disability 363 confident EMPLOYER APPENDIX 1: Map of Hebden Water and surroundings ‘ ™... Bridgewater A / NN Hou: Access track to Bowling Club /“” — fog as / ~ ey Vi ‘pynght and databaes Nght 2010, Ordnance Survey Licence number 0100023069" Courtesy of Calderdale MBC Highways section
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