Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0242, written 1 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2024 |
|---|---|
| Reference | 2024-0242 |
| Deceased | Laura Gawthorpe |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (Eastern) |
| 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.
IN THE WEST YORKSHIRE (EASTERN) CORONER AREA HM AREA CORONER OLIVER LONGSTAFF IN THE MATTER OF LAURA GAWTHORPE REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Parking, Roads and Transport, Leeds City Council 1 CORONER I am Oliver Robert Longstaff, Area Coroner for the Coroner area of West Yorkshire (Eastern). 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 yth October 2022 I commenced an investigation into the death of Laura Gawthorpe 07/07/1987. The investigation concluded at the end of the Inquest on 30/04/2024. The conclusion of the Inquest was that Mrs Gawthorpe's death was a suicide. 4 CIRCUMSTANCES OF THE DEATH Laura Gawthorpe was a voluntary patient at the Becklin Centre, Alma Street, Leeds. On 13th September 2022, she left the Becklin Centre on unescorted leave and made , where CClV tracked her making her way to her way levels , from where she deliberately fell to the ground below, dying instantly from unsurvivable injuries. of the car park, and thence back down 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) The evidence of West Yorkshire Police was that, by the erection of extensive fencing and barriers, measures have been put in place on levels at the car park to make it harder for people to fall from those levels, whether deliberately or accidentally. (2) The erection of similar measures on level has been only partial. The point from where Mrs Gawthorpe fell was identified by correlating her location on the ground with the location on level where she had left her phone before her fall. At that location, the parapet wall could still easily be climbed over. 6 ACTION SHOULD BE TAKEN 1 In my opinion action should be taken to prevent future deaths and I believe you or 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 28/06/2024. 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 to the following Interested Persons; (Mrs Gawthorpe's husband), Leeds and York Partnership NHS Foundation Trust. 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 Signed: 0~ ~------ ,,..,..~.,,,,,,_,,,.,. ,.,.,,..,,.,., OLIV!;R""LONGSTAFF Area Coroner West Yorkshire (E) Date: 01 Mav 2024 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.
HM Coroner Dear Mr Longstaff Civic Hall Calverley Street Leeds LS1 1UR Tel: 1 August 2024 RE: REPORT TO PREVENT FUTURE DEATHS - CASE 330632 - LAURA GAWTHORPE Further to your letter dated 2nd May, 2024 addressed to Head of Service for Regulatory and City Centre Services which includes responsibility for the city’s council car parks. , I can confirm that I am the Council’s Thank you for sharing your report to prevent future deaths following the sad death of Laura Gawthorpe on 13th September 2022 and specifically the evidence provided by West Yorkshire Police in relation to barriers. I have attached, for your information, a copy of our working action plan which sets out the range of measures and actions guiding our response to date and actions going forwards at . We are committed to ensuring we do all we reasonably can to prevent further suicides. was built in the 1960s, it has 1270 spaces across 18 floors. In Just by way of context, 2008 the top levels you have referred to on your report were fenced off and following that there were no incidents for several years. The layout was reviewed again in 2013 when the car park was renovated, and no additional security features were identified. Again, there were no incidents for several years. There was extensive publicity, however, following an incident in December 2021. In retrospect we believe that this sad incident raised the profile of the building as a potential suicide site. The city has recently launched a new Suicide Prevention Action Plan which is referenced and linked into the specific action plan. We are guided by this city-wide plan which is overseen by the Leeds Suicide Prevention Strategic group in all we do in terms of suicide prevention, and specifically the actions in relation to the role of responsible communications in suicide prevention which we believe has been a key factor in this matter. www.leeds.gov.uk general enquiries : 0113 222 4444 Since receiving your report we have been working very closely with a range of partners, including The Samaritans, Leeds City Council Public Health, and internal colleagues including Leeds Building Services, (our internal building services team), health and safety, communications, and our design and architecture technical consultants at Norse Consulting Ltd. to deliver a range of new prevention measures in relation to suicide at . As part of our action plan, we have now finalised a technical specification for additional physical barriers at the locations you have identified on the floor and throughout the car park. A significant part of the car park already has barriers which have been installed at various times since the car park was originally built. Funding for the capital works and approvals to proceed have been secured and we have received high levels of interest from potential contractors to undertake the work as part of the expression of interest stage. We are currently in the process of procuring the works through a tendering exercise within our framework contract for this type of work. A timetable for the procurement and start of works is included below: Task/Milestone Date Expression of interest – market engagement 3.6.24 – 17.6.24 ATP and Governance approvals in line with CPR 3.1.7 17.6.24 Tender published on YorTender Tender submission date Assessment and evaluation Governance and approvals Contract awarded Work on site begins 24.6.24 24.7.24 25.7.24 – 15.8.24 16.8.24 – 6.9.24 7.9.24 21.9.24 We hope that you will agree the Council has responded appropriately and responsibly to the tragic death and that the action plan devised will reduce, as far as possible, the risks of future similar deaths occurring. Please do not hesitate to contact me if we can be of any further assistance in this matter. Yours sincerely Head of Regulatory and City Centre Services www.leeds.gov.uk general enquiries : 0113 222 4444
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