Source · Prevention of Future Deaths

Chloe English

Ref: 2021-0317 Date: 15 Sep 2021 Coroner: Ian Pears Area: West Yorkshire Western Responses identified: 1 / 1 View PDF

Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.

Date 15 Sep 2021
56-day deadline 10 Nov 2021
Responses identified 1 of 1
Suicide (from 2015)

Coroner's concerns

AI summary
Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: is a known location for suicide attempts. It is understood that suicide prevention measures have been installed. However, CCTV footage shows that it took the deceased just under 2 minutes 30 seconds from entering the to jumping off it. My concern is that the current prevention measures are not effective.

Responses

1 respondent
Calderdale Metropolitan Borough Council Local Authority / Fire Service
19 Nov 2021 PDF
Action Taken

Calderdale Council installed anti-climb mesh, steeple coping, and Samaritan signs on North Bridge in 2019 and improved CCTV coverage. Following a death at the bridge, temporary fencing was installed, a suicide prevention group was convened, and a design for further safety measures costing £1.5M has been agreed with Historic England. (AI summary)

View full response
Report for Coroner in respect of fatality at North Bridge Chloe Alice English – 14th May 2021. I, Steven Lee of Calderdale Metropolitan Borough Council write this report on the 19th November 2021 in respect of North Bridge which is situated in Halifax. I am writing in response to a Regulation 28 request from Mr Ian PEARS, HM Assistant Coroner. My current role is Assistant Director Strategic Infrastructure for Calderdale Council, a post I have held since September 2016. Prior to that I held similar roles in both Oldham and Salford within Greater Manchester. I am responsible for all operational aspects of the highway network within Calderdale, a responsibility that also extends to Bridges and other highway structures. North Bridge The current Cast Iron arched bridge was constructed in 1871. The bridge carries traffic and pedestrians over Old Lane, Hebble Brook and the council car park at North Bridge Leisure Centre. The bridge was strengthened in 1991 with the replacement of the central cast iron arch ribs with modern steel arches. The outer cast iron ribs including the decorative parapets were retained to maintain the character of the Grade 2 listed structure. The existing parapet is 1400mm high at its minimum up to 1450mm at its maximum. When the bridge was constructed in 1871 there were no standards for the heights and type of parapets to be provided. Whilst the existing parapet does not meet modern standards in respect of climability (see below) the height did exceed what would be provided today. The current design standard as stated in the Design Manual for Roads and Bridges for a new parapet in this location is 1150mm and with respect to new bridges the manual advises that “it is not practicable to make vehicle parapets completely unclimbable but where pedestrians have access, infilling must be provided and the parapet should not provide toe holds.” Works were carried out in 2019 to ensure that the bridge complies with these standards. The nature of these works is illustrated below. Anti-Climb Mesh and Steeple Coping

In addition to these works the Council also installed Samaritan signs on the bridge and improved CCTV coverage. Since the unfortunate death of Miss English, the bridge has been the subject of further review and the following actions have been carried out:
1. Temporary “Heras” fencing has been installed in order to increase the overall height of the protection even further.
2. A suicide prevention group has been convened specifically to identify ways in which the number of suicide attempts at this location can be reduced. The group, which is multi agency, is considering a wide range of potential interventions which include ways in which improved pastoral care might lead to improvements in overall mental health.
3. As the bridge is a listed structure (and therefore subject to the protection of the Secretary of State) discussions with Historic England have also been undertaken and agreement has recently been reached to progress the design below, which it is estimated will cost in the order of £1.5M to install.

Once the final design is complete the final costs will be calculated and suitable funding will then be sought.

Assistant Director Strategic Infrastructure Calderdale Metropolitan Borough Council.

19th November 2021.

Report sections

Investigation and inquest
On Twenty-First May 2021 I commenced an investigation into the death of Chloe Alice ENGLISH aged 24. The investigation concluded at the end of the inquest on 15/09/2021. The conclusion of the inquest was suicide and the medical cause of death was: I a Traumatic Head Injury I b I c

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Shared signals

Report details

Reference
2021-0317
Date of report
15 September 2021
Coroner
Ian Pears
Coroner area
West Yorkshire Western

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Nov 2021.

Sent to

Calderdale Council

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