Sylvia Price

• 

Department for Levelling  Up, 
Housing & Communities 

Rt Hon Michael Gove MP 
Secretary of State for Levelling up, Housing 
and Communities 
Minister for Intergovernmental Relations 
2 Marsham Street
London 
SW1P 4DF 

Nigel Parsley 
HM Senior Coroner for Suffolk 
Beacon House 
Whitehouse Road 
Ipswich,  Suffolk 
IP1  5PB 

l°Jft.,  June 2023 

Inquest into the death of Sylvia Frances Price: Regulation 28 report 

Thank you  for  your investigative  report of 4  January into the  death  of Sylvia  Frances  Price, 
which was  made  in  accordance  with  Paragraph  7,  Schedule  5,  of the  Coroners  and  Justice 
Act 2009 and  Regulations 28  and  29  of the Coroners (Investigations) Regulations 2013. Your 
report  was  submitted  to  the  Minister  of State  for  Disabled  People  Health  & Work;  and  the 
Minister of State for  Business,  Energy  &  Industrial  Strategy.  I  am  responding  to you  as  the 
finding  of the inquest concerned  signage and  Building  Regulations.  Building  Regulations and 
the  statutory  guidance  supporting  them,  Approved  Documents,  sit  within  my  area  of 
responsibility.  I would  like  to  offer  my sincere  condolences  to  Ms  Price's family  and  friends 
and  also  acknowledge  the  professionalism  of  health  workers  who  cared  for  her  at  Ipswich 
Hospital. 

You set out matters of concern  and  recommended  that I,  in  my capacity as the  Secretary of 
State, should  take  action  to  prevent future  deaths. In this  letter,  I set out the work  currently 
underway  by  officials  in  my  department  and  at  the  Building  Safety  Regulator  to  update 
Building  Regulations  regarding  toilet  provision  and  to  prepare  statutory  guidance  in  a  new 
Approved  Document. There  will  be  a  period  of public  consultation  to  supplement  evidence 
already  held  by  the  department. I can  assure  you  that I will  consider  findings that arise and 
what changes are necessary to reduce the risk of similar incidents in the future. 

At the inquest, evidence was heard that Ms Price had underlying medical issues that required 
an  easily  accessible toilet facility. The  jury concluded  that the lack of appropriate  signage to 
readily  identify  an  easily  accessible  toilet  facility  was  a  contributory  factor  leading  to  Ms 
Price's  death.  The  local  authority  officer  who  investigated  this  case  identified  no  other 
contributing factors and  noted that the  stairs themselves met building and safety regulations. 

The officer's  report  contained  only one recommendation  for  the  premises  owner,  relating  to 
provision  of more  adequate  signage,  which  has  since  been  installed. Your report  noted  the 
officer stated  in evidence that there  was  no  statutory power to  enforce the provision  of such 
signage, and should a premises owner wish to ignore such a recommendation , they could. 

 
 
 The  point  was  also  made  that  there  was  no  requirement  for  signage  of this  nature  in  the 
building regulations for new buildings, so it was not clear what form such signage should take 
even  if an enforcement officer decided that it was necessary. I therefore consider it important 
to  highlight what  legislation  applies to  new  buildings  being  constructed  and  what applies  to 
existing buildings. 

New Buildings 

Building Regulations and  Approved Documents for new build  and construction 
You  noted  in your report that provision  of adequate  accessible toilet facilities  is  now a  legal 
requirement for the majority of buildings designed for public use.  For new build,  or where re­
design or major refurbishment of existing  buildings is anticipated, work must comply with the 
Building  Regulations.  The  Approved  Documents  provide  statutory  guidance  on  how  to 
achieve  compliance. The  Building  Regulations  and  Approved  Documents  ensure  that 
minimum standards for size, space and  materials are incorporated  into new buildings. 

Approved  Document M  ('Access  to  and  use  of buildings  - Volume  2:  Buildings  other than 
dwellings') is the relevant statutory guidance in  such a case.  It sets out design considerations 
for toilet accommodation  (including  wheelchair  accessible toilets)  at  paragraphs  5.5  to  5.10 
and  includes guidance on  other provisions,  e.g.  support rails and  a wash  basin.  Additionally, 
building  design  professionals  are  directed  to  BS8300  which  covers  provision  of signs  and 
information. The  Building  Regulations  apply  to  new  design  and  construction;  they  are  not 
retrospective. A  Building  Control  Body  (including  local authority Building  Control  Officers and 
Approved  Inspectors) will make sure that building  regulations are followed  in new buildings or 
when  building  works  (as  defined  in  the  Building  Regulations  2010)  are  carried  out.  They 
cannot require an  existing  building  where  no  building  works  are completed to be  modified  or 
change its layout. 

Technical changes to  Building Regulations and Approved Documents 
The  Government's  call  for  evidence  on  toilet  provision  for  men  and  women  ended  in 
February  2021.  Following  that,  in  July  last  year,  the  Government  set  out  its  intention  to 
launch  a technical  consultation  on formal  changes to the  Building  Regulations and Approved 
Documents. We are preparing the consultation  document now with a view to publication later 
this  summer. We will  seek views  on  the design  and  range  of toilet provision,  so  that we  can 
prepare  new  statutory guidance. We  will draw  on  evidence  from  commissioned  research  to 
inform  possible  design  suggestions  for  a  variety  of  non-residential  toilet  facilities  including 
wheelchair-accessible  toilets,  toilet  signage  and  labelling. I  will  ensure  that  a  review  of 
Approved  Document M is  coherent with the new statutory guidance we will  prepare  on  toilet 
provision .  We  will  also  take  steps  to  ensure  that  signage  provision  is  given  appropriate 
prominence  in  statutory  guidance  so  that  it  may  be  readily  understood  by  Building  Control 
Officers. 

Existing Buildings 

Whilst  our  work  on  updating  the  relevant  building  regulations  will  address  the  fundamental 
issue  of what signage should  be  provided  in  new buildings,  there are other areas  of existing 
legislation which support appropriate toilet provision for disabled persons which are therefore 
relevant in this case. 

 Health and safety legislation and enforcement 
In  workplaces  (including  hotels) , a need  for signage to  mitigate  risks  (based  on  principles  of 
prevention)  would  normally  be  identified  as  part  of  routine  management  risk  assessment 
procedures;  the  relevant  legislation  is  the  Health  and  Safety  at Work  Act  197 4,  the  Health 
and  Safety  (Enforcing  Authority)  Regulations  1998,  and  the  Management  of  Health  and 
Safety  at  Work  Regulations  1999. Health  and  safety  legislation  requires  every  employer to 
make a suitable and  sufficient assessment of the risks to the health and safety of employees 
and persons who are not in  the  employer's employment but where risks might arise out of or 
in  connection  with  their  business. Local  authorities  are  responsible  for  enforcement  relating 
to premises in their area. 

Equality Act 2010:  reasonable adjustments to existing  premises 
The  Equality  Act  2010  provides  protections  for  people  with  disabilities  who  may  encounter 
difficulties in accessing existing  premises.  Service providers are under an  anticipatory duty to 
make reasonable adjustments to enable customers with disabilities to  use their premises and 
facilities. An  obligation  to  make  reasonable  adjustments  is  continuous. The  Equality  and 
Human  Rights  Commission  notes  that  if a  disabled  person  wants  to  use  an  organisation's 
services  but  encounters  barriers,  then  the  organisation  needs  to  think  about  reasonable 
adjustments whether or not any  adjustments  have  already  been  made.  In  premises open  to 
the  public,  this  may  involve  making  changes  where  barriers  have  been  created  by  the 
physical  features  of those  premises,  or providing  auxiliary  aids  or  auxiliary  services.  In  this 
and  similar cases, providing  appropriate signage to readily  identify an  easily accessible toilet 
facility could be considered an  auxiliary aid. 

Building Safety Regulator 
Finally,  we  have  introduced  a  more  stringent  regulatory  regime  led  by  the  Building  Safety 
Regulator.  The  Building  Safety  Regulator has responsibilities for overseeing  the  safety of all 
buildings,  including  identifying  patterns of regulatory failure  and  making  recommendations for 
improving  standards.  This  will  drive  continuous  improvement  in  buildings  technology  and 
  who  has taken  up the  role  of 
construction techniques.  I have sent your report to 
Director of Building Safety at the Building  Safety Regulator. 

The  Government is  committed  to ensuring  a safe  built environment for all. Thank  you , once 
again, for your report. 

Rt Hon Michael Gove MP 
Secretary of State for Levelling up, Housing and  Communities 
Minister for Intergovernmental Relations