Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0282, written 2 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Aug 2023 |
|---|---|
| Reference | 2023-0282 |
| Deceased | John Shenton |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| 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.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Health & Safety Manager The Range Elsie Margaret House William Prance Road Plymouth PL6 5ZD CORONER I am Mr John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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. INVESTIGATION and INQUEST On the 25th April 2023 I commenced an investigation into the death of John Neil SHENTON. The investigation concluded at the end of the inquest on the 1st of August 2023 with a conclusion of Accidental Death. The medical cause of death was Ia) Bronchopneumonia Ib) Fractured Ribs and II) Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus CIRCUMSTANCES OF THE DEATH On the 17th April 2023 Mr Shenton, together with his wife and son, went to the The Range, Forge Retail Park, Telford TF3 4PB. Mr Shenton was 82 years of age with limited mobility and was to that extent vulnerable. They initially tried to use the lift in the store but it was not in operation. They went to the first floor by escalator and subsequently Mr Shenton fell stepping on the descending escalator. Mr Shenton sustained injury and sadly as a result died 4 days later at the Princess Royal Hospital, Telford on the 21st April 2023. The circumstances of the accident were investigated and are set out in a report from Telford & Wrekin Council Environmental Health Officer. 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 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. – (1) At the inquest you not aware of the report and the recommendations/action required as set out in paragraphs 5.1 to 5.8. (2) Those actions remain outstanding and should be addressed. (3) Essentially whilst the descending escalator was fit safe for a non-vulnerable person more should be done to protect a vulnerable person, particularly if they have to use the escalator when the lift is not in operation. 6 7 8 9 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th September 2023. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner. I have also sent it to , son of the deceased on behalf of the family. 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. Mr John Penhale Ellery Senior Coroner Shropshire, Telford & Wrekin 2nd August 2023
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.
Garden -R Home [RKaN i - g Leisure Response to — 28 oe to a future deaths Dear Mr Ellery Re: The late John Neil Shenton deceased Inquest: 1 August 2023 Location: Coroners Court, Shrewsbury Actions taken and to be taken. We write further to the Inquest touching the death of John Neil Shenton which took place on 1 August 2023 and the related Regulation 28 Report dated 2 August 2023. Firstly, we would like to take this opportunity to again confer our condolences to Mr Shenton’s family. We were deeply saddened to learn of his passing. As you know, an investigation was carried out and a report subsequently produced by | Environmental Health Officer, Telford and Reeking Council. The Coroner's concerns were directly related to the findings of that report and, in particular, the recommendations/actions required as set out in paragraphs 5.1 to 5.8. We think it is important and fair to reiterate the Coroner’s note made in the Regulation 28 Report which stated that we had not been provided with a copy of [J report prior to the inquest and we therefore did not have an opportunity to make appropriate submissions about the report. Nevertheless, listed below are the actions taken in response to the recommendations made by 1.1 Assess site specific risk posed to vulnerable people and others using the escalator to travel to and from the first floor if the passenger lift is not available. This assessment should extend to customers wanting to move large or heavy items between floors. Actions; The escalator and lift risk assessment has been reviewed and updated. ' Appropriate customer information signage will be located at the lift and the escalator in the event of a breakdown, advising customers to seek assistance if they require assistance to move between the floors. Where possible the access route may include the opening of a fire escape staircase provided that there in risk to the customer's safety. When opening new stores or if an existing store is fitted with an escalator, members of staff will be located at the escalators for an initial period to offer guidance and assistance to customers unaccustomed to escalators. Risk assessment amended. 1.2 The daily escalator checks and observations should be recorded. Actions: The existing weekly recorded checklist now incorporates the daily informal visual checks. Head Office Switchboard/Business enquiries T: +44 (0) 1752 725572 W: therange.co.uk Office | Elsie Margaret House | 15 William Prance Road | Plymouth | Devon PL6 5ZD | United Kingdom CDS (Superstores International) Ltd | Company Registration No: 2699203 | VAT Registration No: 591272335 rch: The Range UK WO OOOO Garden -R Home [RKaN i - g Leisure Response to Regulation 28 Report to prevent future deaths 1.3 The illumination readings that are taken by The Range/CDS after an escalator is installed but prior to its use are recorded to demonstrate compliance to BS EN115-1:2017 Actions: CDS have been made aware and the risk assessment amended. 1.4 Staff are trained in how to react if there is a problem with the escalator, including the appropriate use of the emergency button (following the accident on 27/04/2023). Actions: A toolbox talk has been created and issued. Risk assessment updated. Non-mandatory recommendations 1.5 Recommendation that checks put in place to ensure that the time recorded on CCTV footage is accurate. Action: Store advised to make regular checks and amend time if required. 1.6 Recommendation that audible warning be considered to prompt users to embark disembark the escalator. Action: The reasoning for this recommendation is not known. There does not appear to be any evidence that Mr Shenton was unaware that he was about to step onto the escalator and we would respectfully submit that an audible warning would not have improved the safety of the escalator on the day of the incident. We would also therefore respectfully submit that a lack of audible warning should not give rise to an ongoing concern for the Coroner. It is quite common for escalators to operate without an audible warning system in place. In any event, we are investigating the feasibility and likelihood of improved safety of retro fitment of an audible warning system as a matter of good practice. 1.7 Recommendation that obstructions be removed if they block CCTV coverage of the top of the escalator. Action: Item removed. incorporated into risk assessment. 1.8 Recommendation for the addition of high visibility paint to the nosings of the escalator moving treads which could make the edge more visible; this demarcation could encourage users to stand correctly on the step. : Action: To be trialled and the effectiveness and longevity of the paint evaluated. As part of the evaluation the company will consider the level of risk posed by escalators taking into account the speed and Head Office Switchboard/Business enquiries T: +44 (0) 1752 725572 W: therange.co.uk Office | Elsie Margaret House | 15 William Prance Road | Plymouth | Devon PL6 5ZD | United Kingdom CDS (Superstores International) Ltd | Company Registration No: 2699203 | VAT Registration No: 591272335 -R Home E Nn | - Gd g Leisur Garden Response to Regulation 28 Report to prevent future deaths gradient of the installation, as well as historical accident data. We anticipate that the trial will during October 2023. We trust that the above information meets the requirements of Regulation 28 but please do not hesitate to contact me if you require any further information. Yourssincerel Health and Safety Manager (UK and Ireland) Head Office Switchboard/Business enquiries T: +44 (0) 1752 725572 W: therange.co.uk d Office | Elsie Margaret House | 15 William Prance Road | Plymouth | Devon PL6 5ZD | United Kingdom CDS (Superstores International) Ltd | Company Registration No: 2699203 | VAT Registration No: 591272335 earch: The Range UK WO OOOO
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