Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0303, written 19 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2019 |
|---|---|
| Reference | 2019-0303 |
| Deceased | Peter Harrison |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Owners of Stamford Quarter Shopping Centre CORONER ! am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South CORONER’S LEGAL POWERS ! 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 INVESTIGATION and INQUEST On 18" December 2018 | commenced an investigation into the death of Peter Geoffrey Francis Harrison. The investigation concluded on the 1* July 2019 and the conclusion was one of Suicide. The medical cause of death was 1a) Multiple injuries es 4 | CIRCUMSTANCES OF THE DEATH On 17 December 2018 Peter Geoffrey Francis Harrison was found at the bottom of an external staircase at the rear of the Stanford Centre off Brewery Street. The post-mortem examination found multiple injuries including head injuries. There were no suspicious circumstances and there was no third party involvement. Esl UY AVY OTN ole EECUT ONY Nom [eT 5 | CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. 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. The external staircase used by Mr Harrison was to the rear of a shopping area. The inquest heard that access could easily be gained to the staircase and there was no gate that could be locked. The staircase was for maintenance use and did not require regular access by the public. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" November 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Mr Harrison's family, 2) Trafford Council, who may find it useful or of interest. | 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. Alison Mutch HM Senior Coroner 19.09.2019 No
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