Source · Prevention of Future Deaths

Christopher Brookes

Ref: 2018-0055 Date: 22 Feb 2018 Coroner: Zafar Siddique Area: Black Country Responses identified: 1 / 5 View PDF

Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.

Date 22 Feb 2018
56-day deadline 20 Apr 2018
Responses identified 1 of 5
Other related deaths

Coroner's concerns

AI summary
Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.
View full coroner's concerns
[IL1: PROTECT]
1. Evidence emerged during the inquest that there was a previous incident at the same location involving a member of public who narrowly escaped falling to the road below in April 2017 in similar circumstances.

2. Evidence also emerged during the inquest that an alarm would be activated if the fire exit was used. It appears that security guards employed to deal with unauthorised use of the fire exit failed to attend.

Responses

1 respondent
City of Wolverhampton Local Authority / Fire Service
26 Mar 2018 PDF
Action Taken

City of Wolverhampton Council has worked with the health and safety executive and the fire service to review the index area, has installed additional safety lighting on the fire escape route and signage highlighting the drop below, and is working with relevant parties. (AI summary)

View full response
Dear Zafar Christopher Brookes (deceased) - Prevention of Future Deaths Report I write with reference to your Regulation 28. Prevention of Future Deaths Report, dated 22 February 2018. A representative of the Council was present during the course of the Inquest and as such, the Council is aware of the issues and concerns that you have raised. I take the opportunity to respond to your concerns, as set out below.
1. The Council had no knowledge of a previous incident, prior to Mr Brookes’ sad death being notified to the Council. As such, the Council was unaware that there had been a previous incident and has no knowledge as to the circumstances of that incident, whether the incident occurred in similar or entirely different circumstances. As such, the Council was not on notice as to the previous incident occurring.
2. With regard to the alarm being activated, as you may be aware from the evidence given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape aoor from the bus station itself, In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area. With regard to section 6 of your report, I confirm that following Mr Brookes’ sad death, the Council has worked with both the health and safety executive and the fire service, to review the index area, As you may be aware, the Council has no control over the fire escape from (o’itin ed Cly of Woierhampten Ccnci 0 wolverhampton gov.uk IJ\J1 I RL
• WolverhamptonToday

the bus station itself, as detailed below but the Council is able to make changes to the fire escape route and the gate at the end of that. Changes have already been made. Following the incident occurring, the Council has liaised closely with the fire safety authority. The health and safety executive has confirmed that the height and construction of the fencing along the fire escape route is appropriate and meets the relevant regulations. The gate itself has been inspected and maintained, including the push pad mechanism. As you are aware from the Inquest, there is no locking mechanism of similar placed on the gate at the relevant time. In addition to the above, the Council has installed additional safety lighting on the fire escape route, together with signage, highlighting the existence of a drop below the fire escape route. The Council has also committed to working with the other relevant parties, including the combined authority and the other users of the building, to include Sainsburys supermarket, who occupy and area of the ground floor of the building. I trust the above is of assistance. Should you require any further information, please do not hesitate to contact me.

Report sections

Investigation and inquest
On the 8 November 2017, I commenced an investigation into the death of Mr Christopher Brookes. The investigation concluded at the end of the inquest on 22 February 2018. The conclusion of the inquest was a short narrative conclusion of: Accident

The cause of death was:

1a Cranial Trauma
Circumstances of the death
i) Mr Brookes was a 22 year old gentleman who had been out socialising on the 28 October 2017 celebrating a family birthday. ii) He later made his way to the Wolverhampton bus station and around 2am left the station via a fire exit. iii) It appears from the evidence available he tried to climb over a gate whilst leaving through a fire exit and then fell around 40 feet to the road below. iv) He was taken by ambulance to the Queen Elizabeth Hospital in Birmingham, but sadly died from the injuries sustained on the 29 October 2017.
Action should be taken
1. You may wish to consider further reviewing the safety arrangements in place at this location and consider what additional measures can be put into place to try and prevent a reoccurrence.

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Report details

Reference
2018-0055
Date of report
22 February 2018
Coroner
Zafar Siddique
Coroner area
Black Country

Responses identified

Responses identified 1 of 5
4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Apr 2018.

Sent to

Black Country North Fire Safety team
Transport for West Midlands
West Midlands Combined Authority
West Midlands Fire Service
Wolverhampton City Council

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