Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2020-0130, written 17 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2018 |
|---|---|
| Reference | 2020-0130 |
| Deceased | Bertram Crawford |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 13th December 2018 REF: 12849 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Suspension Bridge Trustees 1 CORONER I am M. E. Voisin, Senor Coroner for the Area of Avon 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. 3 INVESTIGATION and INQUEST On 05/12/2018 I commenced an investigation into the death of Bertram Montague Henry Crawford. The investigation is ongoing. 4 CIRCUMSTANCES OF THE DEATH I am currently aware that he was seen to walk alone onto the Clifton Suspension Bridge, then, just before reaching the half way point he stopped climbed over the wire fence and jumped to his death. The details as I said are still being investigated but this is what I am currently aware of. 5 CORONER’S CONCERNS During the course of this investigation the evidence has 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. – This is the 3rd student death from the bridge this year, it being the 4th student death from the bridge in two years. This is obviously on top of the other deaths from the bridge that have occurred. I appreciate that the bridge is a site of historical interest however, this cluster of student deaths is of particular concern and I considered that I had a duty to formally report this to you. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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 such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th February 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 NOK of Bertie Crawford (deceased) NOK of Benjamin Murray (deceased) NOK of Alex Elsmore (deceased) NOK of Lara Nosiru (deceased) 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 17/12/2018 Signature_________________________ Area of Avon Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
CLIFTON SUSPENSION BRIDGE TRUST Bridge Master Clifton Suspension Bridge Leigh Woods, Bristol, BS8 3PA Bridge Master: 0117 973 15 79 Ms M.E Voisin Senior Coroner The Coroner's Court Old Weston Road Flax Bourton Bristol BS48 1 UL Dear Madam, Regulation 28 Report Clerk to the Trustees T J Baines Clifton Suspension Bridge Leigh Woods Bristol, BS8 3PA 11 th February 2019 I am writing in response to the letter dated 20th December 2018 and your Regulation 28 Report to Prevent Future Deaths. You have asked for details of action taken or proposed to be taken, to prevent further deaths at the Clifton Suspension Bridge. I have set out below the actions we have already taken and those that we are planning. The Trust is very aware of the rising mental health issues in the UK and in Bristol. The bridge is seen as the last resort for some people and in 2018 alone our bridge attendants intervened in over 180 incidents, where vulnerable people had come to the bridge in distress. These numbers are not publicised. However, we are acutely aware that we are not able to help everyone and indeed, not everyone wants to be helped, and that is of concern to us. We do not seek acknowledgement or credit for the work of our bridge attendants. However, it was greatly appreciated when last year, Avon & Somerset Police Chief Constable- -and the Police Commissioner for their work with vulnerable people at a ceremony at the bridge. commended our bridge attendants The numbers of vulnerable people our bridge attendants are dealing with each year is increasing, but the number of suicides has remained fairly stable. There are a minimum of two bridge attendants in attendance at the bridge at all times, carrying out regular foot patrols and monitoring the CCTV cameras. I am not aware of any other bridge or location which has similar full time surveillance or patrols. This work has become a major part of the bridge attendants' role. The bridge attendants are trained in negotiation skills, suicide awareness and next month they will be trained in Safe Intervention Training, similar to that used in hospitals. Email: bridgemaster@cliftonbridge.org.uk Incorporated under 1he Cliflon Suspension Bridge Act 1952 www.cliftonbridge.org.uk Registered Charity Number 205658 L.WESTOR IN PUOPLU /"''''°/ < L,fTOJ/SUSPENSIOI! >\i,Ol)f,f THUil Current Arrangements and Future Actions We currently have a team of three bridge attendants during the day and two at night. We are planning to increase the number of bridge attendants to three present at night, as current statistics indicate that this is when the most incidents occur. This change is in the planning process and we will be aiming to implement this later in 2019 as part of our suicide prevention improvements. The bridge is monitored by 31 CCTV cameras in real-time. All areas of the bridge are covered by these cameras. In 2018, we increased the proportion of high definition, low light tolerant cameras, with thermal imaging for viewing at night. We have been investing in these state-of- the-art facilities to help us monitor activities on the bridge as well as we possibly can. In addition, the cameras are linked to alarms that alert Bridge Attendants to pedestrians on the bridge between the hours of midnight and 5.00am. Samaritan signs are installed on both towers and can be seen by anyone coming to the bridge. There are also phone boxes located at each end of the bridge, with the Freephone number to the Samaritans displayed. Recently, we have installed lighting to illuminate the Samaritan signs throughout the night. There is a quiet room at the Clifton side of the bridge where people in distress can sit in private while waiting for the emergency services to arrive. This is being rebuilt at present and once completed will be more comfortable than the current arrangements. Leaflets offering relevant support are available in this room. We also work closely with the emergency services, the Samaritans and local authorities and we have seats on both the Avon Gorge Working Group and Bristol City Council's Suicide Prevention and Audit Group (SPAG). We also continuously share information and experience with our network of operators of long span bridges both in the UK and internationally. Our Bridge Master represents the 'long span bridges' group on the Bridge Owners Forum at Cambridge University. Physical measures are also in place: Anti-climb barriers on the span were installed in 1999 and have been considered best practice by many bridge owners. They are higher than the average for bridges at 1.9m high and are fitted with anti-climb mesh on the footway side of the barriers. In 2006, we upgraded the lighting on the bridge and both footways and buttresses are continuously lit throughout the night, with lights also present at all entrances to the bridge. In 2012, mesh panels were installed on the outside ends of the parapet fences to prevent access onto the span. In 2013, we installed a half-corona barrier on the Clifton South abutment to prevent access to the bridge span along the abutment ledge. Email: bridgemaster@cliftonbridge.org.uk Incorporated under the Clifton Suspension Bridge Act 1952 www.cliftonbridge.org.uk Registered Charity Number 205658 () INVESTOR IN PllOPLil In 2017, we installed covers to the end parapet posts to restrict foothold access onto the buttress walls. We are acutely aware of the importance of reducing access to means for those who wish to attempt suicide. In addition to increasing the number of bridge attendants at night, over the last two years we have been planning further substantial physical improvements to the bridge. The decision to add further physical measures to the bridge is, however, a complex one. There must be a balance between the measures to be taken and allowing the bridge to be enjoyed by the hundreds of thousands of visitors each year. Installing further physical barriers will have an impact on the structure of the bridge and we must ensure that any changes are not detrimental to its safety. We are also severely constrained by planning constraints imposed on us by Historic England. Any changes we want to make require their approval. All the changes we have made to the bridge have to comply with latest legislation and require Planning Permission from the two Planning Authorities and Conservation Officers. Planning considerations include the desirability to preserve the structure, the setting of the structure and the features that are special on the structure. We are now working on the final stages of the next phase of our plan, to press ahead with the most extensive suicide prevention improvements to the Clifton Suspension Bridge for 20 years. We are determined to get these improvements in place as soon as possible and we will be seeking support from a wide range of stakeholders across the Bristol area. These plans include the extending of the height of the parapet anti-climb fencing over the span and building a walkway beneath each of the buttresses. The walkway seeks to balance the changes to the bridge that will deter or mitigate suicide attempts and at the same time enhancing the structure for those that visit it. We do not expect this to be an easy process, as we need to be certain that both are feasible structurally - dealing with wind loading plays a huge part in any structural modifications to the bridge, and visibly- navigating planning and Historic England's approvals. I understand this request is specifically regarding the student deaths at the bridge. I would like to take this opportunity to express our condolences to the families and friends of those who have died. We will keep you informed on the progress of the above measures, and it you have any queries please do not hesitate to contact either myself of the Bridge Master. Chairman For and on behalf of the Clifton Suspension Bridge Trust (Signed on Chairman's behalf by the Bridge Master) Email: bridgemaster@cliftonbridge.org.uk Incorporated under the Clifton Suspension Bridge Act 1962 www.cliftonbridge.org.uk Registered Charily Number 205658 ()...... INVI!Sl'OR IN PBOPLB
See every Prevention of Future Deaths report matching Maria Voisin, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.