Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0212, written 22 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2024 |
|---|---|
| Reference | 2024-0212 |
| Deceased | Chanyang Li |
| Coroner | Melanie Lee |
| 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
Chenyang Li (died 30 September 2023)
THIS REPORT IS BEING SENT TO:
1. Scape Living Student Accommodation, Scape Operations
Ltd, Link Company Matters Limited, Cardale Park,
Harrogate, North Yorkshire HG3 1RY; cc Neil Smith,
Managing Director, 6th Floor, 65 Gresham Street, London,
United Kingdom, EC2V 7NQ
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
An investigation was commenced into the death of Chanyang Li, aged
23 years, on 16 October 2023. The investigation concluded at the end of
the inquest on 5 April 2024. I made a determination at inquest of suicide.
4
CIRCUMSTANCES OF THE DEATH
At the time of his death, Chenyang was a third year undergraduate
student on a BSc Statistics, Economics and Finance degree
programme at UCL. On 30 September 2023 Chenyang returned to
Scape Bloomsbury at approximately 8.30am. He made his way to the
6th floor and let himself in to a friend’s apartment.
Having entered the apartment, Yang went immediately to the window
and climbed out of it, falling onto the concrete below. He died shortly
afterwards from multiple severe injuries.
1
A police investigation described the window as follows: The window
…is situated within the kitchen/lounge space. Window is metal framed,
right side hung. The window has a windowsill in front of the interior side
which is 74ccm from the interior floor, sill width is 38cm from front of sill
to window. Beneath the window is a small fixed panel window. Window
is 125cm from the interior floor, 44cm in width, 76cm in height. At the
time of attendance, the window was open to its widest aperture which is
55cm.
The National Code of Standards for Larger Developments for student
accommodation not managed and controlled by educational
establishments, under which Scope Bloomsbury is accredited, states at
paragraph 6.30: All windows above ground-floor level will be fitted with
stops to prevent over-opening.
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.
Students falling or jumping from windows is a known risk. Chenyang
was able to easily jump to death from a 6th story window. Scope
Bloomsbury is one of a number of is part of Scape Living Student
Accommodation, a provider of purpose designed, student
accommodation. The window Chenyang jumped from does not appear
to have been fitted with any, or sufficient, form of window restrictors at
all or as required under the National Code of Standards accreditation.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 17 June 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
• Family of Chanyang Li
•
Director of Student Support and Wellbeing and
Safeguarding Lead, UCL
• National Code Administrator and Unipol Student Home: 155-157
Woodhouse Lane, Leeds, LS2 2ED
• NUS,
• Association for Student Residential Accommodation,
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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
DATE SIGNED BY ASSISTANT CORONER
22 April 2024
3
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.
Scape Operations Ltd
Managing Director
Assistant Coroner
Link Company Matters Limited
6th Floor
65 Gresham Street
London
EC2V 7NQ
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
14th May 2024
Dear Ms Lee,
Response to Regulation 28 Report to Prevent Future Deaths dated 22 April 2024
I am writing to follow up with a response to your report dated 22nd April 2024 in relation to the tragic incident that took place 30th Sept 2023
at Scape Bloomsbury.
Firstly we would like to again pass on our deepest condolences to the family of Mr Chenyang Li, our thoughts are with his family and friends.
We were not an Interested Person at the Inquest so have not had the benefit of seeing the evidence that you have seen. In that context, we
have reviewed your report and make the following observations regarding window restrictors at Scape Bloomsbury.
In line with the guidance set out by the National Code of Standards for Larger Developments for student accommodation not managed and
controlled by educational establishments (the Code), each window at Scape Bloomsbury is fitted with a window restrictor; these were
installed as part of the complete refurbishment of the building in 2018. The building will have received an inspection/sign-off from an
inspector from The National Code at the time.
Over and above what is prescribed in the Code, the restrictors are periodically inspected every three months {as part of routine inspections
of the condition of the student accommodation], with [on the rare occasion} any required remedial works undertaken immediately. This
information is logged quarterly by the maintenance engineers within the building’s Planned Preventative Maintenance (PPM) system. In
addition to three-monthly inspections of the window restrictors from within the bedroom, the building’s façade is also periodically visually
inspected (weekly) to identify any remedial works required which would include windows appearing to be open beyond the tolerance
allowable by the restrictor. Any issues are remediated immediately and logged by the maintenance team.
The window restrictors in the room in question were last inspected from inside, and formally signed off within the PPM platform as
functioning correctly on 18th August 2023.
We do not therefore propose further action.
One minor point of clarification. The report is addressed to Scape Operations Ltd. The more appropriate entity to address would have been
Scape UK Management, as this is the entity responsible for managing the building. Scape UK Management have been made aware of the
report, and they are in agreement with this response.
I am hopeful that this answers to the recommendations made in the report, however please do not hesitate to contact me should you
require any further clarification or should you wish to make any additional recommendations.
Best regards,
2
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.