Source · Prevention of Future Deaths

Seth Thind

Ref: 2022-0323 Date: 17 Oct 2022 Coroner: Christopher Wilkinson Area: Hampshire, Portsmouth and Southampton Responses identified: 2 / 2 View PDF

A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.

Date 17 Oct 2022

56-day deadline 12 Dec 2022 est.

Responses identified 2 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.

View full coroner's concerns

1. At the incident location there is little if anything by way of safety measures that would prevent anyone from being able to climb over, around or on top of the side railings of the bridge or to prevent them from jumping from the bridge to the carriageway. There is for example no enclosure of the walkway to prevent this.
2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance. There are no signs or signposting for mental health assistance or support (such as from Samaritans).
3. There are no known monitored CCTV cameras covering the bridge or approach area, rendering monitoring of a recognised danger spot actionless.
4. At the incident location, according to Hampshire Police Record Management Systems, there have been 12 crisis incidents in the last 5 years (of which the Police are aware) including 7 self-harm ( jumping) attempts, 2 successful jumps from which the individual has survived and 3 fatalities. There have been a further 89 reported 'concern for safety' incidents at the location.
5. Wider reports of self-harm incidents and fatalities are well known from most of which do not have sufficent safety measures in place (as above) or means of summonsing help at a point of mental health crisis.
6. Deaths continue to occur as a result of individuals jumping from these bridges and insufficient measures have so far been taken to address and prevent their occurrance.

Responses

2 respondents

Hampshire County Council Local Authority / Fire Service

23 Nov 2022 PDF

Noted

Hampshire County Council acknowledges the concerns but states that National Highways is responsible for the bridge in question. They offer to work collaboratively with National Highways to review solutions. (AI summary)

View full response

Dear Karen Inquest touching the death of Mr Seth Curtis Palminder THIND I write in response to the Regulation 28 report relating to the unfortunate death of Mr Thind. My condolences go to Mr and Mrs Thind for the tragic loss of their son, Seth.

The bridge at over the A3( ) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3( corridor, regardless of their primary usage. The bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used is by pedestrians and cyclists.

The action that needs to be taken or considered, together with a timetable for possible implementation, will essentially be for National Highways to consider, as the owner of the bridge asset. That said, the County Council, in its role as the Highway Authority for local roads, which includes rights-of-way, would be happy to work collaboratively with National Highways to review any identified solutions that might help prevent, or certainly reduce the risk, of further incidents occurring at this or other sites.

For your information and reassurance, the County Council has its own highway bridge assets, and where similar risks have been identified highway officers have routinely engaged with other specialist teams and agencies e.g. Hampshire County Council’s Public Health team, the NHS etc, to determine whether an intervention by the Highway Authority is warranted. The County Council will also review and consider advice and guidance from relevant charity organisations, or special-interest groups, that specialise in mental health matters.

2

If you require further information, or clarification, do please come back to me.

National Highways Other

PDF

Action Planned

National Highways will install Samaritans signs by September 2022, add the location to the South East "Network Needs" list by December 2022, add it to the agenda of Hampshire Safer Roads Partnership quarterly meeting in December 2022 and apply for funding for a study into suicide prevention at this location by September 2023. (AI summary)

View full response

1

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS RESPONSE IS BEING SENT TO:

1. The Senior Coroner for Hampshire, Portsmouth and Southampton, Mr Christopher Wilkinson, of 1 Guildhall Square, Portsmouth PO1 2GJ in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Mr Seth Curtis Palminder THIND that concluded on 27 September 2022.

1 NATIONAL HIGHWAYS

I am , Regional Director, South East, responding on behalf of , Chief Executive of National Highways Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ.

2 CORONER’S MATTERS OF CONCERN

The MATTERS OF CONCERN were identified are as follows:–

1. At the incident location

) there is little if anything by way of safety measures

There is for example no enclosure of the walkway to prevent this.
2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance. There are no signs or signposting for mental health assistance of support (such as from Samaritans).
3. There are no known monitored CCTV cameras covering the bridge or approach area, rendering monitoring of a recognised danger spot actionless.
4. At the incident location, according to Hampshire Police Record Management Systems, there have been 12 crisis incidents in the last 5 years (of which the police are aware) –

. There have been a further 89 reported ‘concern for safety’ incidents at the location.
5. Wider reports of

, most of which do not have sufficient safety measures in place (as above) or means of summonsing help at a point of mental health crisis.
6. Deaths continue to occur from these bridges and insufficient measures have so far been taken to address and prevent their occurrence.

3 DETAILS OF ACTION TAKEN

1. Safety Measures The location is fitted with a parapet that met the required standards set out in the Design Manual for Roads and Bridges (DMRB) at the time of construction in 1971 and remains compliant with current standards (DMRB CD 377 Requirements for road restraint systems). This parapet measures 1.65m high, providing a protective barrier. Although historically some structures have been enclosed for a number of reasons, including for suicide prevention or to prevent items being thrown onto the carriageway below, this is not something that highway authorities do now as the enclosed space often sees a rise in antisocial behaviour and criminal activity.

2
2. Signs

In September 2022, we installed four Samaritans “Crisis” signs on the inner faces of the parapets over both carriageways of the A3( ) road below. This features the short 6-digit number anyone in crisis can call from any phone 24 hours a day to reach a trained Samaritans volunteer.

3. Working with Partners We have raised the subject with the “Hampshire Safer Roads Partnership” and suicide prevention has been added to the agenda for the next quarterly meeting due to take place in December 2022. The Hampshire Safer Roads Partnership is comprised of Hampshire Constabulary, Hampshire County Council, Hampshire Fire & Rescue, Southampton City Council, Portsmouth City Council, Isle of Wight Council, and National Highways. The aim is to forge a link with the local Public Health team and the Hampshire Suicide Prevention and Intervention Network if such a network exists.

4 DETAILS OF FURTHER ACTION PROPOSED

1. Network Needs List We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups. The “Network Needs” list provides a way of prioritising and promoting the highest priority areas, locations, and structures, with the proposed schemes and studies meeting the highest needs attracting the required funds to go ahead.
2. CCTV If funding is secured and a study is carried out which finds that CCTV installation is a recommended outcome, then a CCTV scheme would be submitted for future funding. If it were to be installed, CCTV at the location would be monitored from our Regional Operations Centre at Godstone, Surrey as part of a wider network of cameras covering the SRN in the South East.
3. Working with Partners We will seek out and engage with the relevant public health and suicide prevention teams and personnel in the area to promote courses such as the Samaritan’s campaign “Small Talk Saves Lives” training to inform local residents and others on how to recognise the signs of potential crisis and how to approach a person in crisis in an appropriate way to offer them the assistance they may need.
4. Other Structures None of the other local structures on the southern (Hampshire) aspects of the stretch of the A3(

3

It is however clear that there is a need to work more closely with Hampshire Constabulary to establish clear lines of communication to ensure the police make us aware of such events when they relate to the SRN.

5 TIMETABLE FOR ACTION

DATE ACTION

September 2022

December 2022

December 2022

September 2023 Samaritans “Crisis” signs installed

Added location to the South East “Network Needs” List

Added to agenda of Hampshire Safer Roads Partnership quarterly meeting

Apply for future funding for a study into the prevention of future suicide events at this location

6 SAFETY OF ROAD USERS

The safety of everyone on our road network matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation in how we go about it. Our Suicide prevention strategy outlines our continued contribution to delivering the cross-government national strategy for suicide prevention. As part of our strategy, we assess and prioritise sites across the SRN for the delivery of crisis interventions and suicide prevention measures, working in partnership with the Samaritans and the local authority public health teams.

7

09 December 2022 Signed:

, Regional Director on behalf of

Report sections

Investigation and inquest

On 17 February 2022 I commenced an investigation into the death of Seth Curtis Palminder THIND aged 25. The investigation concluded at the end of the inquest on 27 September 2022. The conclusion of the inquest was that Mr Thind had taken his own life impulsively whilst suffering an acute episode of anxiety whilst under the effects of Sertraline intoxication.

Circumstances of the death

At approximately 20.10 on the evening of Sunday 6 February 2022 the Deceased fell from a road bridge as a result of which he was instantly struck by a number of southbound vehicles who had no time to avoid the collision, resulting in his instant death due to multiple injuries. The Deceased had, on Friday 4 February 2022, been discharged from Antelope House in Southampton where he had been receiving care under an informal admission since 27 December 2021 for what was believed to be emotionally unstable personality disorder and following an incident of arson at the family home. His discharge had been delayed due to difficulties in finding suitable alternative accommodation for him as he had been unable to return to his family home. This resulted in temporary lodgings having to be found for him, at short notice, as he was presenting as homeless pending a further move to new accommodation on the following Monday 7 February 2022. It was recognised at the time of his discharge that there were risks of further self-harming or reckless behaviour, but despite attempts by the crisis resolution home treatment team to engage with him in the 48 hours following his discharge, he was unable to be contacted. He was found to have taken an overdose of prescribed medication on the evening of 5 February 2022 for which he was hospitalised, but then discharged on the morning of 6 February. It was determined likely that he had taken a further overdose of medication during the day of 6 February 2022, which resulted in his presenting at the road bridge at close to his temporary accommodation,

The evidence established that on the balance of probabilities he had impulsively jumped from the bridge with the intent to take his own life whilst under the influence of an overdose of prescription medication.

Copies sent to

Hampshire PoliceForensic Collision Investigator

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Report details

Reference: 2022-0323
Date of report: 17 October 2022
Coroner: Christopher Wilkinson
Coroner area: Hampshire, Portsmouth and Southampton

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Dec 2022 (estimated).

Sent to

Hampshire Highways

Highways England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.