Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0046, written 18 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2025 |
|---|---|
| Reference | 2026-0046 |
| Deceased | Stephen Page |
| Coroner | Ian Potter |
| Coroner area | Kent and Medway |
| 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.
Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: 03000 410502 Email: kentandmedwaycoroners@kent.gov.uk Date: 18 December 2025 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Chief Executive Officer, MAPP, 180 Great Portland Street, London, W1W 5QZ (2) Chief Executive, Hempstead Valley Shopping Centre, Gillingham, Kent, ME7 3PD 1. CORONER I am Mr. Ian Potter, Area Coroner for Kent and Medway. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 19 August 2025 I commenced an investigation into the death of Stephen Paul PAGE, aged 70 years at the time of his death. The investigation concluded at the end of the inquest heard by me on 17 December 2025. The conclusion of the inquest was: Suicide The medical cause of death was: 1a Ascending Aortic Wall Dissection With Haemothorax And Neck Fracture 4. CIRCUMSTANCES OF THE DEATH On the morning of 17 August 2025, Stephen Page drove alone to the multi-storey car park of Hempstead Valley Shopping Centre in Gillingham. . Despite efforts to treat Mr Page, a paramedic verified the fact of his death on scene at 10:42 on 17 August 2025. Mr Page died as a result of the traumatic injuries he sustained. He had intended his actions to bring about his death. 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows. - (1) Written evidence from a senior member of staff at MAPP (who provide security management at Hempstead Valley) set out that there is an electronic sensor system in place The evidence was that, "When the sensor beam is broken, the corresponding CCTV camera automatically moves to the activation point and displays a visual alert marked 'Alarm'. The camera remains focused on the area to allow for monitoring if an operator is present." The investigating officer from Kent Police, said in their statement, "This 'alarm' is visual only and displays for a few seconds. Due to the number of screens, this could have been easily missed by the CCTV operator." For the avoidance of doubt, the evidence suggested that the alarm system was working and operational on 17 August 2025. Further, there was no evidence of a delayed response in this particular instance. However, it is not difficult to envisage (particularly given that there is no audible alarm) a situation in which a triggering of the 'alarm' could be missed and an opportunity for staff to intervene being lost. 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 by 12 February 2026. 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: • Mr Page's family. 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. She may send a copy of this report to any person who she 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. 18 December 2025 Signature Ian Potter Area Coroner for Kent and Medway
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.
MAPP 6th February 2026 FOA Mr Ian Potter Area Coroner Kent and Medway Coroners’ Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Re: Touching on the death of Stephen Paul Page - Regulation 28 Dear Sir We write in response to the 'Regulation 28 Report to Prevent Future Deaths’ dated 18 December 2025, received on 28 January 2026. MAPP manage the building on behalf of our client and therefore we are responding on behalf of the centre manager ( The matters identified in the Report have been considered. In response we can confirm that action has been taken in respect of: ) whom you also address the Report to. (cid:127) An audible alarm system linked to on-site security arrangements in the relevant area. (cid:127) Instruction to enhance the physical perimeter safety measures (completion of all physical measures will be April) 2026. » Action has been taken to arrange for suicide prevention awareness training to be delivered on site by an external provider. These matters are being addressed through established management and governance processes. 180 Great Portland Street (please change these details if needed) London W1W 5QZ 020 7908 5500 info@wearemapp.com MAPP is the trading name of MAPP (Property Management) Limited 180 Great Portland Street, London W1W 5QZ Company reg number. 03602713 wearemapp.com MAPP We thank you for your correspondence in this matter and our thoughts are with the family during this difficult time. Yours faithfully Chief Executive Officer 18G Great Portland Street (please change these details if needed) London W1W 5QZ 020 7908 5500 info @wearemapp.com MAPP is the trading name of MAPP (Property Management) Limited 180 Great Portland Street, London W1W 5QZ Company reg number: 03602713 wearemapp.com
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