Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0297, written 6 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Sep 2021 |
|---|---|
| Reference | 2021-0297 |
| Deceased | Joseph Dent |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. ,Chief Executive Officer, Durham County Council 1 CORONER I am Jeremy Chipperfield, senior coroner for the coroner area of Durham and Darlington 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. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5/enacted https://www.legislation.gov.uk/uksi/2013/1629/regulation/28/made https://www.legislation.gov.uk/uksi/2013/1629/regulation/29/made INVESTIGATION and INQUEST 3 On 28 June 2021 I commenced an investigation into the death of Joseph William DENT, aged 18. The investigation concluded at the end of the inquest on 02 September 2021. I found that the deceased died as a result of sustaining multiple injuries after falling from the bridge known as Newton Cap Viaduct (“the bridge”), Bishop Auckland and recorded an open conclusion (it was unclear how he came to fall). 4 CIRCUMSTANCES OF THE DEATH Joseph was seen to park a car close to the bridge in the early hours of 20 June 2021 and his body was found close to its base shortly after 08:00 hrs. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear (1) the bridge’s parapet and railing is accessible to pedestrians on the bridge; (2) the bridge is frequently discussed on social media as suitable location for suicide by jumping; (3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and (4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall 1 gave evidence that: Detective Sergeant (a) there is pedestrian access to either side of the bridge; (b) the bridge lacks effective measures to prevent persons climbing over the parapet; (c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media); and that (d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge. Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians. My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation 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 02 November 2021. 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: I have also sent it to the Chief Constable of Durham Constabulary and DS who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 2 9 Signed by: JEREMY CHIPPERFIELD H M Senior Coroner for County Durham and Darlington Dated: 6th September 2021 3
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.
Jeremy Chipperfield H M Senior Coroner Civic Centre North Terrace Crook DL15 9ES Dear Mr Chipperfield, 29 October 2021 Re: Response to REGULATION 28 REPORT TO PREVENT FUTURE DEATHS for Newton Cap Viaduct I am writing to you in response to the request made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 on the 7th September 2021. This request relates to the tragic death of Joseph William Dent, aged 18 from Newton Cap Viaduct, which occurred on 20th June 2021 and was investigated by your office from 28th June 2021. The conclusion of the Outcome of Mr Dent’s death is registered as an Open Verdict. The death of Mr Dent has led to you raising Matters of Concern which require Durham County Council to consider action in regard to the following points: 1) the bridge’s parapet and railing is accessible to pedestrians on the bridge; 2) the bridge is frequently discussed on social media as suitable location for suicide by jumping; 3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and 4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall Durham County Council take the prevention of suicide very seriously. We host a Suicide Prevention Alliance which brings a range of partners together including primary care, Durham Constabulary, Fire and Rescue, mental health services and VCSE to implement evidence-based plans based on the recommendations made by Public Health England Continued… Chief Executive Durham County Council, County Hall, Durham DH1 5UF Main Telephone (03000) 26 00000 Text Messaging Service 07860 093 073– Your message must start with the word: INFO www.durham.gov.uk (PHE) to reduce rates of suicide within local communities. The Alliance meets on a quarterly basis and was maintained throughout the Covid-19 pandemic. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/939479/PHE_LA_Guidance_25_Nov.pdf As you are aware, we have developed a Real Time Data Surveillance (RTDS) system which works in partnership with your Office to monitor potential deaths by suicide in County Durham. Any deaths occurring within a particular timeframe (between 6-12- months), within a specific geographical location, or indicating the potential for social connections between deaths initiates a Multi-agency Assurance Review (MAAR) meeting. The MAAR enables partners to consider any community response required to prevent the rippling effect of the death as recommended by PHE. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/839621/PHE_Suicide_Cluster_Guide.pdf The death of Mr Dent triggered a MAAR on 24th June 2021, which resulted in a community response in the Bishop Auckland area. This comprised of action including: • • the dissemination of information relating to community mental health and wellbeing support services via network channels including local GP’s, schools, the Area Action Partnership (AAP) and local workplaces. the mobilisation of Educational Psychologists, Child and Adolescent Mental Health Services (CAMHS) Crisis Teams and Emergency Departments to ensure any requirements for early interventions were fast tracked. • Engagement of If U Care Share (IUCS) as the commissioned service for post- • vention referral. training provided to local community and voluntary sector organisations on suicide prevention. • Consideration of the potential to implement lighting and CCTV on the viaduct (subject to a Feasibility Study and Planning Application). • Actions planned in the area in a lead up to World Mental Health Day (10th October 2021). In terms of your concerns about the reporting of potential deaths by suicide on social media, this provides a challenge for all local councils. Work is taking place on a regional Integrated Care System (ICS) basis to explore methods for addressing the issue directly with social media companies. However, the County Durham Public Health Department continues to advocate recommendations made within Samaritans Media Guidance and regularly liaises with media outlets to help promote sensitive reporting on suicides. Corporate social media methods are also used to promote positive mental health and wellbeing messages to de-escalate public perceptions. Samaritan signage is present on Newton Cap Viaduct with relevant support phone numbers for those finding themselves in distress. https://media.samaritans.org/documents/Media_Guidelines_FINAL_v2_TABa8C6.pdf Floral tributes for those involved in road traffic accidents may exacerbate the perception that suicides from this location are frequent. We have worked with the council’s Area Action Partnership and local Elected Members to try and address these perceptions without drawing further attention to the viaduct as a high frequency location. The Council’s RTDS system suggests there have been 3 deaths by suicide since 2014. Continued… However, there seems to be a small discrepancy in the Regulation 28 Report data suggesting this is over the last 5-years. Data supplied by County Durham Fire Service indicates they have received 10 callouts to the viaduct since 2009 (YTD) relating to suspected suicides/ suicide attempts. Durham Constabulary data suggests they received 37 call outs for the period September 2020 to August 2021 relating to concern, collapse, injury or illness. However, this data cannot be disaggregated to be more specific in relation to suicide attempts. We are trying to rectify this issue by continuing to work with police colleagues to enable their data fields to reflect the number of call outs relating to attempted suicide. In 2018, the Council’s Public Health department produced a High Frequency Location Report for Suicide Prevention, which reviewed a number of high-risk geographical locations across County Durham, including Newton Cap Viaduct. This review initiated a Feasibility Study (2019) which was undertaken to assess options for any suicide prevention measures specifically for Newton Cap Viaduct. After the unprecedented public health protection pressures on the Council during the Covid-19 pandemic subsided, a further options appraisal was developed, and a preferred option (Option 1) was identified. On 15th September 2021, the Council’s Corporate Management Team (CMT) requested further detailed work be undertaken on Option 1 to consider the possibility of mounting an additional fence to the face of the concrete parapet upstand of the structure on both east and west elevations. This Option is regarded as the only one that will offer a significantly increased level of suicide prevention. This more detailed work also includes the requirement for assessments on the impact for road traffic accidents if a barrier was to be installed, Listed Building Consent, Planning Consent and a full design and approval process. The council is currently sourcing an external consultant versed in the speciality of ‘designing out suicide’ to progress next steps. Any changes made to the viaduct will depend on the ability of the structure’s foundations to host any suggested measures whilst also accommodating wind speeds and the needs of local residents, road users, cyclists and conservation. A provisional date for the completion of this assessment work still requires formal confirmation from the provider. The assessment process will also include any potential for lighting and CCTV to be implemented at an earlier stage (yet to be confirmed), which addresses concerns raised in the Regulation 28 report. A Suicide Prevention Reference Group has been initiated to project manage this work and govern the representation of residents and people using the viaduct and the paths below. This group met for the first time on 11th October 2021. Full updates from this group on progress of this work can be given to your Office on a regular basis. I hope this information provides you with an overview and assurance of the work undertaken by Durham County Council to reduce deaths from suicide across the county and more specifically in regard to Newton Cap Viaduct. Please do not hesitate to contact us again if you require further information or recommend any further action to that set out. Yours sincerely, Chief Executive Officer
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