Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0007, written 10 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2020 |
|---|---|
| Reference | 2020-0007 |
| Deceased | Muhammed Wajid |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (West) |
| Category | Suicide (from 2015) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Kirklees Council 2. Highways England _| 1 | CORONER lam Oliver Robert Longstaff, HM Assistant Coroner for the coroner area of West Yorkshire (Western District) 2 | 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. 3 | INVESTIGATION and INQUEST On 17" September 2018 ! commenced an investigation into the death of Muhammed Wajid, aged 29. The investigation concluded at the end of the inquest on 7" January 2020. The conclusion of the inquest was that Mr Wajid’s death was due to multiple injuries sustained in a fall from Scammonden Bridge onto the westbound carriageway of the M62 motorway, and the jury concluded that the death was a suicide. 4 | CIRCUMSTANCES OF THE DEATH On 12"" September 2018, Mr Wajid was observed by passers by to be standing adjacent to the fence of Scammonden Bridge in a manner giving rise to concerns for his safety. Police officers attended, and he was safely removed from the scene pursuant to the provisions of $.136 of the Mental Health Act 1983. Following an assessment at Airedale Hospital, Mr Wajid agreed to be admitted to Lynfield Mount Hospital, Bradford, as a voluntary patient. On the following morning, Mr Wajid was permitted unaccompanied leave from Lynfield Mount, and took a taxi to Scammonden Bridge, where he was seen to jump to his death. 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 fo you. The MATTERS OF CONCERN are as follows. (1) Scammonden Bridge is a locally notorious location for suicides. (2) Reports to prevent future deaths have been made to Kirklees Council and Highways England under the above statutory provisions following deaths occurring in similar circumstances. (3) Kirklees Council and Highways England have reported proposed steps to prevent future deaths to the coroner following a similar report. The coroner is not aware whether those steps have been fully actioned. ACTION SHOULD BE TAKEN “| In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 6" March 2020. |, 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: Mr Wajid’s family and the Bradford District Care NHS Foundation Trust. lam 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. 10" January 2020 istant Coroner | va
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for West Yorkshire (Western District), Mr
Oliver Robert Longstaff, of City Courts, The Tyrls, Bradford BD1 1LA
in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an
inquest hearing into the death of Muhammed WAJID that concluded on 07
January 2020.
i | HIGHWAYS ENGLAND |
| Tam Mr Jim O'Sullivan, Chief Executive of Highways England Company Limited of
| Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 41Z. |
| Following the inquest into the death of Mr Wajid and the overlap in the subject matter, I
have responded in a similar way to the Regulation 28 Report we received recently on the
same matters of concern from the West Yorkshire (East) Coroner Area in relation to the
inquest into the death of Jessica Louise Duckworth.
2 | CORONER'S MATTERS OF CONCERN
The MATTERS OF CONCERN were identified as follows:—
a. Scammonden Bridge is a locally notorious location for suicides.
b. Reports to prevent future deaths have been made to Kirklees Council and
Highways England under the above statutory provisions following deaths
occurring in similar circumstances.
c. Kirklees Council and Highways England have reported proposed steps to
{ prevent future deaths to the coroner following a similar report. The coroneris |
i not aware whether those steps have been fully actioned. |
DETAILS OF ACTION TAKEN
a. Fencing;
Highways England has carried out a technical study to identify an alternative
pedestrian barrier, previously referred to as a “suicide prevention parapet”
(2.4m high), to be installed alongside a new vehicle safety barrier nearer to the
edge of the B6114 local authority road owned by Kirklees Council that crosses
the Rainbow Bridge. :
Highways England explored options for a higher combined pedestrian and
vehicle restraint parapet in the past. These were not progressed due to
structural concerns for the bridge in light of the additional load that a
“combined” parapet would place on the bridge. However, we are now able to
address this through the use of an inboard vehicle safety barrier which removes
i from the new parapet the requirement to deal with vehicle impact loads.
The current proposed works for Scammonden Bridge comprise a 2.4m high
parapet with a large top tube and vertical infill rails. The parapet has a slight
inwardly curve profile in elevation to discourage climbing. Chevaux-de-frises (a
row of blunt spikes) will be attached at the ends of each parapet to prevent
access to the bridge outside of the line of the new parapet. The double yellow
lines on the B6114 across the bridge will be refreshed, and along with the
inboard safety barrier this should discourage parking on the bridge.
The scheme has been designed in detail and agreed in principle with Kirklees
Council as the Highway Authority for the B6114 Saddleworth Road. Due to the
| ; technical complexity of the scheme, the proposals are being checked by a third-
L
party consultant. Highways England plans to install the new parapet and vehicle
restraint system (“the bridgeworks scheme”) during the Spring / Summer 2020,
provided no issues with the scheme are identified by the third-party consultant.
Other measures;
Additional measures have been identified at the location;
1, The closure of an “unofficial layby” on the B6114 local authority road at the
south-eastern edge of the bridge to prevent vehicles ftom parking in the
vicinity of the bridge. Kirklees Council have deployed large concrete blocks
to make the area inaccessible;
2. The upper rail of the new parapet has been designed to include LED lighting |
to illuminate the footway area between the parapet and the vehicle restraint
system. This should make any person on the bridge more conspicuous to
the road users on the B6114 local authority road that runs across the bridge
and on the M62 motorway below, providing an opportunity for road users to
alert the emergency services;
3. The installation of an alert / help telephone system, in conjunction with
West Yorkshire Police. The alert / help telephone will be linked to a module
using a mobile phone SIM card and a send / receive unit which dials out to
999 or the Samaritans using pre-installed numbers based on the user's
choice by button press. Mobile phone coverage has been checked for the
surrounding area and coverage is noted as being “good” for all networks.
The system comprises a box similar to the highway emergency telephone
unit with an additional loudspeaker and beacon above the box (“the SOS
point”), enabling the police to “dial out” and speak to someone on the
bridge. There will be one telephone unit at each end of the bridge;
4. The installation of a camera surveillance system, in conjunction with West
Yorkshire Police. Two fixed thermal cameras along with a dual thermal &
colour CCTV camera with full pan / tilt / zoom capability will be installed to
cover the footways on each side of the bridge. These will be linked to an
electronic cordon which will alert the police control centre as soon as
someone leans over the parapet. The combined system will enable the
police to view each incident as it occurs to determine if an attempt at self-
harm is taking place, thereby speeding up an emergency response (where
necessary), working in conjunction with the remote “dial out” ability of the
SOS points, as well as reducing false alerts. The electronic cordon has been
designed to work with both the current and proposed parapets.
5. Apermanent power supply has been installed to provide electricity for the
LED lighting, SOS telephone system and camera surveillance system
6. The alert / help telephone system at the southern end of the bridge has been
constructed and is operational
7. The camera surveillance system has been constructed and is fully
operational.
4
DETAILS OF FURTHER ACTION PROPOSED
a.
Fencing;
Subject to the successful completion of the detailed design and third-party
checks, the installation of the bridgeworks scheme is planned to be carried out
during the Spring / Summer 2020.
b. Other measures;
a ~ 4
1. Permanent physical measures to enforce the closure of the “unofficial layby” |
will be installed as part of the bridgeworks scheme, to replace the concrete
! blocks currently deployed by Kirklees Council;
2. The LED lighting will be installed as part of the bridgeworks scheme;
3. The alert / help telephone system will be constructed with the bridgeworks
scheme and will become operational when the bridgeworks are completed;
4. Highways England is also in contact with East Sussex County Council, who
face a similar issue whereby vulnerable passengers in crisis have used taxis
and private hire vehicles to access Beachy Head. We arelookingtoshare
any learning or suitable measures they may have identified that could be \
applied to Scammonden Bridge.
re |
{5 | TIMETABLE FOR ACTION |
| | DATE ACTION
| 2019/20 Detailed design of the proposals and bid for internal delivery funding
for the bridgeworks scheme, and delivery of the alert / help telephone
system
2020/21 _ Delivery of the bridgeworks scheme
ee:
SAFETY OF ROAD USERS
The safety of everyone on our road network matters; it is an imperative for our business |
in what we set out to achieve, and a core value of our organisation in how we go about it. |
We published our suicide prevention strategy and toolkit in November 2017 outlining
our continued contribution to delivering the cross-government national strategy for ,
suicide prevention. As part of our strategy, we are assessing and prioritising sites across |
the strategic road network for the delivery of crisis interventions and suicide prevention
measures, working in partnership with the Samaritans and the local authority public
health teams on our proposals. }
7 | COPIES
} | I respectfully ask that a copy of my response be forwarded to the Interested Persons to
| the-inquest and your Regulation 28 Report (dated 10 January 2020), as well as Kirklees
| Council and the local Samaritans’ as the partners involved in the collaboration with
Highways England to prevent future deaths at this location.
I respectfully ask that a copy of my response be forwarded to the relevant taxi and
private hire licensing authorities who cover the areas identified in the circumstances of |
Mr Wajid’s death to raise awareness of the carriage of similarly vulnerable passengers |
| attempting to access Scammonden Bridge on the B6114 Saddleworth Road and the M62
} motorway as a means of suicide.
2March2o020 Signed:
L
| linia Director on behalf of i
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