Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0394, written 8 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2022 |
|---|---|
| Reference | 2022-0394 |
| Deceased | Leanne Dunn |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| 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.
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 16th September 2022 I opened an inquest into the death of Leanne DUNN, aged 44. The investigation concluded at the end of the inquest on 8th December 2022. I found that the deceased died having sustained multiple traumatic injuries after falling from the bridge suicide. . I concluded that her death was 4 CIRCUMSTANCES OF THE DEATH Leanne was seen to climb up from the footpath, turn around and push herself backwards off the bridge at Newton Cap. 5 CORONER’S CONCERNS During the course of the inquest, 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. Although it remains my duty to report this matter to you (since the circumstances of concern continue to exist), I note the steps that Durham County Council has taken, and proposes to take, to address these concerns (see below and in your attached letter dated 30th November 2022). The MATTERS OF CONCERN are as follows. – All concerns relate to the bridge footpaths up to around 30m (100ft) above the reiver Weir , which carries a road and two (1) the bridge’s parapet and railing is accessible to pedestrians on the bridge; (3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and 1 (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. The body of a further person was found at the foot of the bridge on 3rd December 2022 in circumstances which may be consistent with his having fallen from the top of the bridge. Thank you for your letter dated 30th November 2022 (a copy of which is attached hereto and part of the contents of which were read at inquest); in it you have informed me about various measures which have been implemented and more which are due to be implemented to address these matters and to reduce the risk of future deaths. 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-Feb-23. 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. I acknowledge that these matters are answered in your aforementioned letter. 8 COPIES and PUBLICATION I have sent a copy of my report (with attachment) to the Chief Coroner and to the following Interested Persons: I have also sent it to the Chief Constable of Durham Constabulary. 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. 9 8th December 2022 END 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.
Ms J Ives Coroner’s Officer HM Coroner County Durham and Darlington Fourth Floor Civic Centre North Terrace Crook Co Durham DL15 9ES Dear Mr Chipperfield 21 December 2022 Thank you for providing the Regulation 28 report following the inquest into the death of Leanne Dunn. As you note in the report, Durham County Council provided a written submission to the inquest, dated 30 November 2022, which addresses the points raised. Having reviewed the Regulation 28 report and the letter of 30 November, I do not feel that there is anything further to add at this stage, other than to reaffirm the commitment of Durham County Council to suicide prevention. Should you require any further specific information in response to the Regulation 28 report, please let me know. Kind regards Chief Executive Officer Chief Executive Durham County Council, County Hall, Durham, DH1 5UF www.durham.gov.uk
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