Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0317, written 15 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 | 15 Sep 2021 |
|---|---|
| Reference | 2021-0317 |
| Deceased | Chloe English |
| Coroner | Ian Pears |
| Coroner area | West Yorkshire Western |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE WEST YORKSHIRE (WESTERN) CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Chloe Alice ENGLISH A Regulation Report – Action to Prevent Future Deaths __________________________________________________________ REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Calderdale Council…………………………………… 2 …………………………………… 3 …………………………………… 1 CORONER I am Ian PEARS, HM Assistant Coroner for the area of West Yorkshire Western Coroner Area 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 Twenty-First May 2021 I commenced an investigation into the death of Chloe Alice ENGLISH aged 24. The investigation concluded at the end of the inquest on 15/09/2021. The conclusion of the inquest was suicide and the medical cause of death was: I a Traumatic Head Injury I b I c II 4 CIRCUMSTANCES OF THE DEATH On 14th May 2021 Chloe Alice English walked to the fencing and jumped to her death, dying from a traumatic head injury. , Halifax, deliberately climbed over 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: is a known location for suicide attempts. It is understood that suicide prevention measures have been installed. However, CCTV footage shows that it took the deceased just under 2 minutes 30 seconds from entering the prevention measures are not effective. to jumping off it. My concern is that the current 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/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 10 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 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 Ian PEARS HM Assistant Coroner for West Yorkshire Western Coroner Area Dated: 15 September 2021
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.
Report for Coroner in respect of fatality at North Bridge Chloe Alice English – 14th May 2021. I, Steven Lee of Calderdale Metropolitan Borough Council write this report on the 19th November 2021 in respect of North Bridge which is situated in Halifax. I am writing in response to a Regulation 28 request from Mr Ian PEARS, HM Assistant Coroner. My current role is Assistant Director Strategic Infrastructure for Calderdale Council, a post I have held since September 2016. Prior to that I held similar roles in both Oldham and Salford within Greater Manchester. I am responsible for all operational aspects of the highway network within Calderdale, a responsibility that also extends to Bridges and other highway structures. North Bridge The current Cast Iron arched bridge was constructed in 1871. The bridge carries traffic and pedestrians over Old Lane, Hebble Brook and the council car park at North Bridge Leisure Centre. The bridge was strengthened in 1991 with the replacement of the central cast iron arch ribs with modern steel arches. The outer cast iron ribs including the decorative parapets were retained to maintain the character of the Grade 2 listed structure. The existing parapet is 1400mm high at its minimum up to 1450mm at its maximum. When the bridge was constructed in 1871 there were no standards for the heights and type of parapets to be provided. Whilst the existing parapet does not meet modern standards in respect of climability (see below) the height did exceed what would be provided today. The current design standard as stated in the Design Manual for Roads and Bridges for a new parapet in this location is 1150mm and with respect to new bridges the manual advises that “it is not practicable to make vehicle parapets completely unclimbable but where pedestrians have access, infilling must be provided and the parapet should not provide toe holds.” Works were carried out in 2019 to ensure that the bridge complies with the se standards. The nature of these works is illustrated below. Anti-Climb Mesh and Steeple Coping In addition to these works the Council also installed Samaritan signs on the bridge and improved CCTV coverage. Since the unfortunate death of Miss English, the bridge has been the subject of further review and the following actions have been carried out: 1. Temporary “Heras” fencing has been installed in order to increase the overall height of the protection even further. 2. A suicide prevention group has been convened specifically to identify ways in which the number of suicide attempts at this location can be reduced. The group, which is multi agency, is considering a wide range of potential interventions which include ways in which improved pastoral care might lead to improvements in overall mental health. 3. As the bridge is a listed structure (and therefore subject to the protection of the Secretary of State) discussions with Historic England have also been undertaken and agreement has recently been reached to progress the design below, which it is estimated will cost in the order of £1.5M to install. Once the final design is complete the final costs will be calculated and suitable funding will then be sought. Assistant Director Strategic Infrastructure Calderdale Metropolitan Borough Council. 19th November 2021.
See every Prevention of Future Deaths report matching Suicide (from 2015), 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.