Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0258, written 25 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2019 |
|---|---|
| Reference | 2019-0258 |
| Deceased | Stanislawa Kmiecik |
| Coroner | Laurinda Bower |
| Coroner area | Nottinghamshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: URBN UK Ltd (Company number 03124253) 1 CORONER I am Laurinda Bower, HM Assistant Coroner for Nottingham City and Nottinghamshire 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://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 10 June 2019, I commenced an investigation into the death of Stanislawa Kmiecik, who died on 12 April 2019 as a result of 1a. Multiple Injuries An inquest touching her death is yet to take place. CIRCUMSTANCES OF DEATH Stanislawa Kmiecik entered the Urban Outfitters store in the Victoria Shopping Centre, Nottingham, on the afternoon of 12 April 2019. She made her way across the shop floor, and accessed a concrete mezzanine floor via a gate just off of the main shop floor. This area is not supposed to be accessed by members of the public, rather it is an area intended for staff to access in order to display merchandise and signage, but it is visible and was accessible from the shop floor where members of the public are free to roam. The concrete mezzanine floor has two open spaces leading to the basement shop floor approximately 18 feet below. Mrs Kmiecik entered the open space and fell to the floor below sustaining multiple injuries consistent with a fall from height. She died at the scene. CORONER’S CONCERNS 4 5 Having reviewed the evidence received to date and having visited the scene there are matters giving rise to a concern of a risk of death to staff or members of the public accessing the area. 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. – (1) There is a drop of some 18 feet between the mezzanine floor and the basement shop floor below that is accessible via a gate from the shop floor where persons are free to roam (2) There is no signage highlighting the risk of fall (3) Whilst the area is cordoned off from the main shop floor by way of a locked mesh gate and some scaffolding type posts, it remains possible for staff and/or members of the public to access the area. ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> (4) Although members of staff have been told not to access this area of the shop, I remain concerned that in the absence of signage, a new or inexperienced member of staff may seek access to that area either by unlocking the gate or by climbing over the gate (as has happened in the past). (5) If a member of staff or the public were to access the area, there remains a risk of falling from height as there is no safety netting or other safety structure below either of the two openings in the mezzanine floor. (6) The surface area surrounding the openings is uneven and in a state of disrepair, posing a trip hazard to any member of staff or the public in the vicinity and increasing the risk of inadvertently falling from height. (7) Further, any item that is dropped in that area, or is thrown over the gate, could fall through the opening and onto staff/members of the public below. ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take action in relation to the above matters: (1) URBN UK Ltd 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 September 2019. I, the coroner, may extend the period. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Kmiecik’s family and INTU (as the Management company for the Victoria Shopping Centre), Nottinghamshire Constabulary and the Environmental Health Office of Nottingham City Council 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. 9 25/07/2019 Signature_________________________ Laurinda Bower Assistant Coroner Nottingham City and Nottinghamshire ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>>
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.
URBN UK LTD,
24 West Street,
London
WC2H 9NA
Tel: +44 (0) 203 119 2905
Fax: +44 (0) 203 119 2901
Laurinda Bower
Assistant Coroner
Nottingham City
The Council House
Old Market Square
Nottingham
NG1 2DT
24th January 2020
Dear Madam
Stanislawa Kmiecik
Response to Regulation Report to Prevent Future Deaths
This letter is sent by way of an updated response to your Report dated 25 July 2019. The incident
remains under investigation by Nottingham City Council, the competent regulatory body to enforce
health and safety legislation. Nottingham City Council has not served any Notices on URBN relating to
the incident which require improvements or prohibit certain activities or state of affairs.
We do not wish to pre-judge the evidence that will be heard at the inquest. However, it does seem plain
that the cause of the incident was almost certainly a deliberate attempt by the deceased to put herself
in a position of danger and potentially take her own life. There can be no other credible explanation for
the individual unsecuring the gate or climbing over the gate and then going beyond the scaffolding. No
member of the public has ever attempted previously to access the area beyond the gate.
In terms of the action that has been taken since the incident:
•
•
the broken lock was replaced on Monday 15 April 2019 ;
immediately after the incident all moveable items beyond the gate were removed and all
members of staff were instructed not to access the area beyond the gate unless authorised to
do so. That instruction not to access the area beyond the gate has been repeated and will
cover new members of staff ;
URBN UK LTD,
24 West Street,
London
WC2H 9NA
Tel: +44 (0) 203 119 2905
Fax: +44 (0) 203 119 2901
•
•
•
•
•
signage has been placed adjacent to the gate indicating no unauthorised access ;
removal of all of the scaffolding and replaced with high railings throughout ;
infilling the voids with steel plates ;
installation of a pulley system to lower the grids to a safe height to update the visual displays ;
authorised members of staff have been trained in the use of harnesses when working in the
area beyond the gate. Harness equipment has been purchased and is stored in a locked
cupboard in the display room.
We trust this response satisfies the Report.
Yours faithfully,
Emily Lofting-Kisakye
HR Director
URBN Europe
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