Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0124, written 4 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2024 |
|---|---|
| Reference | 2024-0124 |
| Deceased | Sandra Senior |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report Sandra Elizabeth SENIOR (died 24 September 2023) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, London Borough of Camden Council, 5 Pancras Square, London, N1C 4AG 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 6 October 2023, an investigation was commenced into the death of Sandra Elizabeth SENIOR, then aged 58 years. The investigation concluded at the end of an inquest, heard by me, on 28 February 2024. The conclusion of the inquest was suicide, the medical cause of death being: 1a multiple traumatic injuries 4 CIRCUMSTANCES OF THE DEATH On 24 September 2023, Sandra Senior travelled to central London. While there she gained access to Tavistock Chambers, Bloomsbury, WC1A; a building comprising of commercial units on the ground floor, with four floors of residential accommodation above. completed suicide 5 CORONER’S CONCERNS During the course of the investigation and 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:- (1) The London Borough of Camden Council is the Freeholder of Tavistock Chambers. I learned in evidence from local witnesses and officers from the Metropolitan Police Service that Miss Senior’s death, as a result of using the second of its type within approximately 18-months. to complete suicide, was The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. , which has “a secure key There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access .” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed , it that although there was a clear ‘no entry’ sign was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building time. were not working effectively at that was The concern is that it appears that the safety systems in place to stop unauthorised access in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 29 April 2024. 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 the following Interested Persons: (a) Miss Senior’s family members 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 Potter HM Assistant Coroner, Inner North London 4 March 2024
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.
Date: 26 April 2024 Mr Ian Potter HM Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Mr. Potter, London Borough of Camden Supporting Communities Directorate 5 Pancras Square London N1C 4AG Regulation 28 – Prevention of Future Deaths Report Sandra Elizabeth SENIOR (died 24 September 2023) Thank you for your report dated 4th March 2024. We were saddened to read your report and the circumstances of the death of Sandra Senior. This letter sets out the enquiries we have made in relation to your recommendations, and the steps we have taken to address the risks identified. Communal front entrance door On the communal door we have removed the latch and hook so that the door cannot be held in the open position. The door entry system was operational at the time of our visit, and we have a specific contract in place for the maintenance of door entry systems should a fault occur. Roof top exit For the roof top exit we have installed an extra “Fire Brigade” lock that requires a different key. It is unfortunately the case that suited keys that are used by the London Fire Brigade, and our maintenance teams, can be procured by members of the public who wish to access restricted areas (for example for recreational use or pirate radio station broadcasts). This can lead to roof top exits, or doors to machinery and intake cupboards, being left open at times. Hopefully the addition of this further lock will deter casual access. Caretaking service The caretaking service carries out daily checks and will secure roof top exits and communal entrance doors that are left open or report a fault should there be one. Clearly this can allow some elapsed time between each daily check where a door may be left open, however the frequency of inspection is determined by the resources available for the service. Residents can also report faults, or doors left unlocked, directly to the repairs service. I hope this letter sets out clearly our approach to managing the risk in relation to roof top exits, and the specific issues identified at this block. Again, we were saddened to hear about the passing of Ms. Senior, and we welcome the report that you provided following the inquest. Yours sincerely, Director of Property Management Executive Director, Supporting Communities
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