Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0259, written 13 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jul 2020 |
|---|---|
| Reference | 2020-0259 |
| Deceased | Luiz Anjos |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Mental Health related deaths · Railway 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.
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: Highways Agency Essex County Council 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 8 November 2019 I commenced an investigation into the death of Luiz Claudio Ramos Dos Anjos (jnr) a 21 year old man who died on 7 November 2019 at on the railway track at St Dominic’s footbridge Colchester. The conclusion of the inquest was:- the deceased killed himself whilst suffering from a diagnosed mental illness. The deceased had a substantial history of mental illness stretching back over a number of years. CIRCUMSTANCES OF THE DEATH See above The medical cause of death was 1a) multiple traumatic injuries 1b) train collision. 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. – The BTP post incident site report reported the following:- 1. No crisis signs at the location 2. Relatively easy access over the footbridge parapet and sides. It is my understanding that point 1. has been remedied but not point 2. The family of the deceased has photographs of the location which can be sent on to you. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 4 5 6 7 YOUR RESPONSE 1 You are under a duty to respond to this report within 56 days of the date of this report, namely by [DATE]. 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 – British Transport Police 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 13 July 2020 Caroline Beasley-Murray senior coroner Essex 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.
Sent By E-Mail Mrs C Beasley-Murray Essex Coroner's Service, Essex County Council, County Hall, Market Road, Chelmsford, CM1 1QH Dear Mrs Beasley-Murray, 13 November 2020 Our Ref: Re: Regulation 28 Report to Prevent Future Deaths – Mr L C Ramos Dos Anjos I am writing to update you regarding St Dominic Road Footbridge, Colchester following our initial letter to you dated 25 August 2020 Following the concerns you raised within item five of your report, I can confirm that your recommendations have been explored further and our inspection report has been finalised. As a result of our option study, we can confirm that we identified three potential options of improvement for the structure: - Option One To install an enclosed mesh canopy to the entire footbridge - Option Two To install a solid screen extension to the top of the existing bridge parapet - Option Three Installation of full height panels resulting in corrugated steel parapets Our preferred option is option three. Our initial investigations suggest that this option provides more durability to the structure, along with providing preventative measures to reduce the possibilities of further incidents occurring in the future at this location. Engineers within my team also believe that option three will provide better value for money for Essex County Council and furthermore, option three will result in the least impact upon the existing structural capacity of the footbridge. The bridge now needs to undergo a full structural assessment and this is estimated to be completed by the end of January 2021. Once the bridge has undergone a full engineering assessment, the design of any refurbishment works can commence. The design is estimated to take approximately twelve weeks to complete, should no additional strengthening works be necessary. Please note, if it is agreed to provide these works the chosen option must be agreed by Network Rail, as the footbridge travels over the train line and is extremely close to overhead cables. Once designed, the works are likely to last an estimated six weeks to complete. I trust that the above information is useful however please contact me should you have any further concerns. Once the structural assessment has been completed, we will endeavour to provide you with a further update. Yours sincerely, – Structures Manager Essex Highways CC: (British Transport Police), (British Transport Police), (Network Rail)
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