Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0500, written 11 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2024 |
|---|---|
| Reference | 2024-0500 |
| Deceased | Emma Harper |
| Coroner | Michael Pemberton |
| Coroner area | Manchester (West) |
| Category | Road (Highways Safety) related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 National Highways 2 Salford City Council 1 CORONER I am Michael James Pemberton, HM Assistant Coroner for the coroner area of Manchester (West). 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 10 May 2024 I commenced an investigation into the death of Emma Victoria HARPER aged 52. The investigation concluded at the end of the inquest on 09 September 2024. The conclusion of the inquest was Suicide, and the medical cause of death was: I a Blunt Force Chest Trauma I b I c II 4 CIRCUMSTANCES OF THE DEATH The deceased had a complex mental health history with a number of suicide attempts and self-harm having occurred in the months leading up to her death. The most recent occurred on in March when she swallowed batteries and was admitted to Salford Royal Hospital for a period between 25 March 2024 and 12 April 2024. A subsequent attendance following ingestion of batteries occurred on 26 April 2024. On discharge from hospital on 12 April there were delays in being referred to an appropriate mental health team in the community. On 1 May 2024, the deceased presented at Salford Royal Hospital and underwent a mental health assessment with the mental health liaison team, this resulted in a low risk assessment despite the previous attempts to take her own life and a referral to Living well was made. A referral was made to the urgent assessment team on 2 May 2024 by staff at the listening lounge after it was reported by the deceased that she did not feel she could keep herself safe. On 3 May 2024 she was assessed and accepted by the Home Treatment Team and daily Regulation 28 – After Inquest Document Template Updated 30/07/2021 visits were arranged with a care plan being agreed. The deceased left home at some point from the evening of 3 May 2024 and was subsequently seen on CCTV at approximately 5:25 on 4 May 2024 walking towards the bridge under which she was found She was discovered below a footbridge on the M602 on 4 May 2024 having fallen onto a crash barrier at the side of the motorway from the bridge above and no signs of life were observed. Death was declared at 06:40. On the balance of probabilities, the deceased fell from the foot bridge above having intended to do so to take her own life. The injuries she sustained in the fall caused her death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) 1. During the course of evidence it was stated that the foot bridge which the deceased fell from had not been considered suitable for amendments to be made to the level of barrier which would prevent a pedestrian crossing the bridge from easily climbing over and falling onto the highway below. 2. Other bridges in the locality were considered and selected for an increase in the height of the barrier or other works to prevent the risk of falling from the bridge onto the M602 motorway. 3. It was unclear on what basis the foot bridge that the deceased fell from has been excluded from such works and there is a risk that this bridge may still be accessed by people who may be at risk of falling as an alternative to other bridges were works had been undertaken in the locality. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 November 05, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Greater Manchester Mental Health Trust Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have also sent it to who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 11th September 2024 Michael James Pemberton Assistant Coroner for Manchester West Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
Our ref:
Your ref:
Mr Michael Pemberton
Assistant Coroner for Manchester West
HM Coroner’s Court and Office for Manchester
West
Paderborn House
Howell Croft North
Bolton
BL1 1QY
Operations Regional Director
Piccadilly Gate
Store Street
Manchester
M1 2WD
www.nationalhighways.co.uk
05 November 2024
Dear Mr Pemberton
Reg 28 Report – After Inquest HARPER EV 04052024
Thank you for your correspondence dated 11 September 2024.
National Highways is committed to maintaining the safe use of the Strategic Road Network
and we appreciate the issues surrounding suicide incidents and the impact these can have.
We continually assess incidents that occur on our network to identify locations where action
may be required.
Due to the nature of the Strategic Road Network, particularly in urban areas such as Greater
Manchester, there are a large number of bridges over the motorway and a limited amount
of funding to progress improvements. We use available historical information to identify
frequently used locations and then prioritise sites to maximise the benefits that can be
achieved coupled with our duty to manage public funds.
In relation to the M602 a study of suicide related issues along the route was undertaken in
2022, specifically in relation to the number of incidents occurring at bridges and structures
spanning the route. The
footbridge that you have raised as a concern was
one of eight structures included in this assessment. It was identified that an increase in
parapet fence height from the standard 1 metre to 1.8 metres was a potential intervention
but noted that the boundary is difficult to effectively secure around the bridge itself. The
footpaths along
which run for several hundred
metres alongside and above the M602 have concrete boundary walls of approximately the
same height as the existing bridge parapet fence.
and
Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ
National Highways Limited registered in England and Wales number 09346363
Increasing the parapet fence height from the standard 1 metre to 1.8 metres can cost up to
£1m per bridge. In addressing concerns surrounding these sites we are constrained by the
available funding and the benefits that can be achieved. We therefore prioritise locations
with the highest number of suicide related incidents. This is the reason that some bridges
have already received upgraded parapets, as historically they have exhibited a far higher
which crosses the M602 adjacent to
level of risk. An example in this area is
.
During the current road investment period (2020-25) in the North West region we have
increased parapet fence heights to 1.8 metres at six of our bridges with the highest number
over the M60 in
of suicide related incidents. These are
of the M60, and
and
at Junction
and
,
and
over the M56 in Wythenshawe.
When assessing the available information relating to suicide related incidents along the
footbridge during the five-year study
M602, there were three recorded at the
assessment period from 2017 to 2021, none of which had resulted in an injury or fatality.
We therefore currently have no proposals to increase the parapet fence height at
footbridge.
In comparison the nearby bridges at
recorded 68
incidents during the same period. Several other bridges spanning the M602 have also
recorded significant numbers of incidents and schemes for these are currently being
developed for potential implementation during the next road investment period from 2025-
30.
We will continue to monitor and assess all locations in the North West in the future where
these types of incidents are recorded, and take the appropriate actions where necessary.
I hope that you find this information helpful.
Yours sincerely
Operations Regional Director
Email:
Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ
National Highways Limited registered in England and Wales number 09346363
20/11/2024, 15:49:28 Subject: RE: Regulation 28 Letter for Salford City Council - Emma Harper Sent: From: To: Cc: Importance: High CAUTION External E-Mail: Take extra care before clicking links, attachments and actioning requests. Think Before you Click Hello Please find below the response on behalf of Salford City Council – apologies for the delay in getting it to you. Salford City Council have been in discussion with National Highways regarding this matter. They confirmed that the bridge structure, parapets and retaining walls on are National Highway assets. As such we believe they are looking into the feasibility of remedial works at this location following this recent incident. Salford will assist and support in terms of any Temporary Traffic Regulation Orders, temporary traffic management etc as required that might impact our network. I believe that National Highways have already emailed their response to your office outlining the above and they are to share a copy with Salford so that we are all fully informed on any proposed way forward. If you need anything further relating to this matter then get back to me. Regards Traffic Management, Parking Services & Road Safety E Salford City Council Civic Centre, Chorley Road, Swinton M27 5AW From: Sent: 14 November 2024 10:24 To: Subject: RE: Regulation 28 Letter for Salford City Council - Emma Harper Some people who received this message don't often get email from Good morning, . Learn why this is important We would be grateful for an update regarding the Reg 28 request. Kind regards HM Coroner’s Court and Office for Manchester West Paderborn House Howell Croft
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