Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0540, written 23 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2025 |
|---|---|
| Reference | 2025-0540 |
| Deceased | Saranveer Sihota |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| 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: 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: Chesterfield Borough Council 1 CORONER I am Peter Nieto, senior coroner for Derby and Derbyshire coroner’s area. 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 29 February 2024 I commenced an investigation into the death of Mr Saranveer Singh Sihota aged 42. The investigation concluded at the end of the inquest on 25 September 2025. The inquest was a jury inquest as Mr Sihota was a detained patient under the Mental Health Act 1983 at the time of his death. The conclusion of the inquest was: - Suicide 4 CIRCUMSTANCES OF THE DEATH Mr Saranveer Singh Sihota (known as Sunny) died on Friday 23 February 2024 at in Chesterfield. He died due to injuries sustained Immediately before he had been perched on the low perimeter wall of the top storey. a height of approximately 70 feet. Sunny was a detained patient at the then Hartington mental health unit at the Callow site in Chesterfield. He had left the unit without permission and without the knowledge of staff staff and police were unable to dissuade Sunny from his actions. 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: has a relatively It is reported to me that the low wall to it. Given the height of the top floor there appears to be a clear risk that, either deliberately or accidentally, people might fall to the ground with high chance of death. I am not aware of what barriers there may be to the perimeters of the lower floors. The police officer who enquired into Sunny’s death has provided the following list of incidents to me (please note this was a quick search which is believed to be an underestimate of the number, and notably does not include Sunny’s tragic death): - CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 I note that Sunny instructed the taxi driver to travel directly from the mental health unit to the , indicating his knowledge of the opportunity this provided to take his own life. It may reasonably be considered that others with thoughts of suicide may similarly consider that location. 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 December 18, 2025. 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 , Sunny’s mother , Sunny’s aunt Derbyshire Healthcare NHS FT , Sunny’s father I have also sent it to Derbyshire Police who may find it useful or of interest. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 23 October 2025 Peter Nieto Senior coroner Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Peter Nieto Senior Coroner Derby and Derbyshire Dear Mr. Nieto, Date: 15.12.25 RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS This is Chesterfield Borough Council’s response to your report made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 23 October 2025, following the tragic death of Mr. Saranveer Singh Sihota on 23 February 2024. We extend our deepest sympathies to the family of Mr. Sihota and also thank you for your conduct of the inquest and for your identification of matters of concern. Within your report you raise concerns about the top floor of having a relatively low wall and that given the height of the top floor there appears to be a clear risk that, either deliberately or accidentally, people might fall to the ground with high chance of death. You have asked us to consider actions we have taken or could take to prevent future deaths at this site. Chesterfield Borough Council undertook a full investigation following the tragic death of Mr. Sihota, focusing on what measures could be taken to prevent future death or injury. first opened in 1981, with all floors including the top floor being used for car parking. Following Mr. Sihota’s death, the top floor of the car park was closed to the public immediately utilising temporary fencing. A full closure scheme with enhanced suicide prevention measures was then developed to prevent any unauthorised access to the top floor permanently. This included the installation of full height, heavy duty gates and fencing. The permanent enhanced closure for the top floor of the car park was completed in March 2024.The following photos have been supplied to show the suicide prevention measures installed: Photos 1, 2 and 3 show the heavy duty fencing installed to prevent members of the public from climbing on ledges to reach the top floor of the car park Photos 4 and 5 show the use of heavy duty fencing to close gaps between the sixth floor and top floor Photos 6 and 7 show the heavy duty locked gates installed to prevent members of the public from accessing the car ramp to the top floor of the car park In addition to the which opened in July 2019. In the 38 years owns a multi-storey car park at between the construction of the two car parks, construction standards have changed significantly, and suicide prevention measures were built into the construction of the new Saltergate car park. , Chesterfield Borough Council Once again, we would like to take the opportunity to thank you for highlighting these matters of concern, and for giving us the opportunity to respond. We will continue to regularly review the effectiveness of the suicide prevention schemes at both sites. Yours sincerely, Service Director for Leisure, Culture and Community Wellbeing
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