Source · Prevention of Future Deaths

Samantha MacDonald

Ref: 2016-0036 Date: 5 Feb 2016 Coroner: Jennifer Leeming Area: Manchester (West) Responses identified: 2 / 2 View PDF

A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.

Date 5 Feb 2016

56-day deadline 1 Apr 2016 est.

Responses identified 2 of 2

Other related deaths Suicide (from 2015)

Coroner's concerns

AI summary

A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.

View full coroner's concerns

Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford, The window was not required to be used as a fire exit because it was too high: The window was fitted with a device that_restricted the_distance for_which it_would open:_Evidence_was_heard that the device complied with the relevant British Standard and Planning regulations: If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha's exit: It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool_ It was not possible to discover exactly when the device had been broken although it had been working during Samantha's tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time: The building is non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window; thus lessening the risk of persons falling either accidentally or otherwise: It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald

Responses

2 respondents

Campus Living Villages

27 Apr 2016 PDF

Action Taken

CLV has reviewed its risk assessment and measures in place to protect student safety relating to opening windows, provided training to CLV staff on mental health, put in place key communication channels to support staff, and developed a Residential Life Programme to foster a sense of community; a clear crisis management procedure has been introduced. (AI summary)

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Dear Madam Response to Regulatlon 28 report relating to the death of Samantha Jane Macdonald We write in response t0 your report dated February 2016 and Ihank you for Ihe additional time provided in responding Al Campus Living Villages ("CLV" ) we look Ihe death of Ms Macdonald extremely seriously and, having listened t0 the evidence provided a} inquest and noled your comments made in Ihe Regulalion 28 repon, we have reviewed our risk assessmeni and the measures in place to prolect sludent, as well as worker, safety relaling lo opening windows: Allhough CLV property to students a universily (a5 opposed (0 adults in privale rental setting) , we remain landlord and are resiricled by leases in our ability t0 enter flats without nolice: Additionally, we do not consider ourselves Io be in the same risk category _ or with the same legal dulies (or powers) , as the healihcare organisations referenced in your Regulation 28 report: However; we wish to do all we can t0 prevent future similar death and to leam Irom Ihis tragic accidenl: Measures In place to this incldent to prevent an accidental or deliberate fall from winows As was heard al inquest, (he window reslrctors in place at the time of Samantha Macdonald"s dealh had been upgraded (owards the end or 2006 and complied with British Standards (BS EN
14351) which were the relevant standards at Ihe time Prior to 25 October 2015, we had recognised; (hrough risk assessment, that risks existed of a fall from wndows il window restriclors were removed or broken, To address this rsk, we: Campus Llvlng vlllages 144001161 667 9815 Repistered Address; London Wall West Mediocilyuk Infoeeclvuk coM London Uriled Kingdom ECZY SEB Quay nysludcnlvlllage.Corti VAT Rcalstratlon Nuynber: 945 6523 Tralfon Whad Road Compally Number: 06604074 Hanchesicr Unlted Klngdom MI7 1HH living rents prlor

Induded specilic prohibilion in 'The Village Rules' , which students have t0 sign Up t0 when renling properly This slates 'The window opening reslrictor system is for your safely must not be inlerlered with or removed Violation ot Ihis policy may; at Ihe discrelion ol Village management; result in disciplinary action (ine: Carried out checks ol the flals each student term and prior to new sludent intake in September, induding specific checks on wndow restnctors Where window restrictors had been damaged or (ampered with, CLV fixed Ihe restrdors and issued Ietler t0 Ihe student concerned informing Ihem 0f the potential for fines andlor disciplinary action should Ihey break the window restndor Conduced specilic risk assessments (or specific aclivties which enhanced risk and set out conlro measures t0 address risk: These included risk assessments for wndow cleaning and (or summer holiday rental of CLV flats when children would be presenl in the accommodalion: Further actlon taken following Samantha Macdonald & death We have considered evidence heard at inquest and, following incident, undertook revew of risk assessments relating to (alls from windows New risk assessments specifically separaling risks of an accdent (all from those linked (o deliberate act resulting in fall were prepared and are enclosed wilh Ihis response_ Preventng risks from an accidental fall In relation t0 risks associaled with accidental (alls, associaled with broken or damaged restrictors, or those which are ineffective for any other reason (e.g. opened for work purposes) additional steps have now been put in place on lop of those in place at Ihe time of incident These include: daily walk around undertaken by slaf: on sile to check trom Ihe oulside 0l the building if any window reslncors have been overcome This also assists to identify if students are doing s0 t0 smoke (rom windows: Action Is taken against students in (he event an issue is identified (rom the daily walk around and restrictors are put back in place work is laking place at CLV properties which requires the removal of window restrictors, warning signs are in place and separale safety procedures are developed: We have specifically considered the suggestion made &l inquesl that (he application of force (rather than use of tool) could result in window restricors breaking In the conlext of accidenlal falls , this has been considered and eliminaled 85 risk and one that it is controlled through the use ol restriclors complying with BS EN 14351. Preventing risks from deliberate act We have considered the comments made in your Reguiation 28 report aboul the polenlial use 0 secondary restricors andl or more robust devices As set out at Ihe start Of Ihis report;, We do not consider CLV to have (he same risk prolile or duties (and powers) ot healthcare organisation. We do however recognise the importance of identifying and helping to support the menlal heallh of students in our propenies We consider that the mosl efteclive wBy can reduce the risk 0 and and again: When " Put = reel

deliberale act causing fall through its windows is to focus on mental heallh programme ralher Ihan by use of additional window restriclors_ CLV Is embarking on global campaign (o support those who suffer with mental health issues whilst residing one of ils villages wilh &n objective to become Ihe globel best in industry (or its mental health model To do so, we are working with nelional and regional charities {hat specialise in Iho suppon ol young people with menlal heallh challenges and we are working in pannership wilh universilies lo develop Ihinking: project was agreed as global priority for CLV in August 2015 and the commencement of the menial health initialive commenced in late 2015. This incident emphasised the importance of the project and CLVs mental health model (whilst still in its early slages) which has develped signilicantly since Ihe incident: Specilically relevant to preventing further incidenl similar to Samantha Macdonald $ since the incdent we have: Provided (ralning to CLV staff on mental health to assist slafl to idenlify and support issues identified; Put in place key communication channels to support staff alfected residents In Ihe event that an issue is identilied which suppor; Developed Residential Life Programme which includes planned events, gatherings and promotional campalgns to bring residents together and foster - sense of community aimed al improving menlal heallh end supparting those who could be suffering; Inlroduced clear crisis management procedure in the event thal il is required: We recognise Ihat lackling menlal health issues is an extremely difficult challenge for organisations and whilsi the above measures will assist large number ol residents, CLV cannot prevent all incidenls where student makes decision t0 Iake their own Ilfe: We do not cansider thal putting in place additional or more robust window reslrictors Is the mosl etlective or appropnale control measure I0 prevenl studeni eaths in normal university setting _ However; as with many olher organisations and businesses in the UK, CLVis committed (0 help reduce the sligma around menlal healih and to encourage residents lo ask for help and others to and support and understand how (hey can help_ We hope Ihat the delail provded about CLV $ commilment t0 developing leading menlal health model will provde some comfort (o (hose concemned about risks faced by students residing in CLV properties including HM Coroner: If HM Coroner would like any furlher detail aboul (he issues discussed above, please contact us and we would be happy to provide further information:

Department fro Business Innovation and Skills Central Government

17 Jun 2016 PDF

Action Planned

The Department proposes to write to UUK and GuildHE by early July to ask them to ensure that HEIs are doing all they can to ensure the safety of students in such accommodation, including the points made concerning risk assessment and replacing window restrictors. (AI summary)

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Dear Ms Leeming, SAMANTHA JANE MACDONALD- DECEASED Thank you for your letter of 22 March addressed to the Secretary of State, about the death of Miss Samantha Jane MacDonald, and your subsequent email of 19 granting an extension am replying as this matter falls within my portfolio. First of all may take this opportunity to send my sincere condolences to Miss MacDonalds family: was very saddened to hear of Miss MacDonald's death: would be grateful if you could treat this letter as my response for the purposes Of paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 May |, in advance, apologise to Miss MacDonald's family if this letter appears overly formal Unfortunately the nature of this process requires a certain degree of formality. am, however; deeply conscious of their tragic loss. In your report you raise concerns, in respect of student accommodation, about the need for risk assessments to be reviewed and consideration given to replacing restrictors with more robust devices to lessen the risk of persons falling either accidently or otherwise out of open windows have considered carefully your concerns and offer the following in response_ should explain that Higher Education Institutions ("HEIs") are independent and autonomous from Government; and are thus responsible for their own processes and procedures_ In preparing this response, my officials have consulted with organisations in the higher education sector and other interested parties, but ultimately it is the responsibility of the HEIs themselves to adhere to the law_ note that the campus where Miss MacDonald was residing is managed by a private company, City Living Villages ("CLV") , which provides student accommodation . Your May

understand that in response to your report; CLV have provided details of measures already in place prior to Miss MacDonald's death, that recognise that there is risk of a fall from a window if restrictors are removed or broken: In addition, following the incident have undertaken a review of risk assessments relating to falls from windows and new risk assessments have been prepared relating to accidental falls from windows, associated with broken or damaged restrictors, or those which are ineffective, as distinct from those linked to a deliberate act resulting in a fall: In relation to risks associated with accidental falls, CLV noted additional measures which have now been put in place in addition to those in place at the time of the incident: understand that the University of Salford has signed up to a 'National Code of Standards for Larger Developments': http Il nationalcode org Upload/FilelNationalCode_Private pdf also understand the Codes are produced by a consortium of organisations Accreditation Network UK (ANUK), Unipol and the National Union of Students and have been developed for purpose-built student accommodation and set the standards for the day-to-day management of the building, including any safety issues: The Codes are voluntary schemes whereby accommodation providers commit to maintaining professional benchmark standards for managing large student developments_ The Codes are fully supported by the Department for Communities and Local Government; the Chartered Institute of Environmental Health Officers (CIEH), Conference of University Business Officers (CUBO) , the Association for Student Residential Accommodation (ASRA), and Universities UK (UUK): However, my Department proposes to write to UUK, whose members consist of Vice- Chancellors, and GuildHE, representative body for higher education providers, by early July, to ask them to ensure that HEIs are doing all can to ensure the safety of students in such accommodation. In that letter we will also raise the points you have made concerning risk assessment and replacing window restrictors with more robust devices. hope that you have found my response helpful: conclude by again expressing my deepest condolences to Miss MacDonald's family.

Report sections

Investigation and inquest

On Tuesday 3rd November 2015, I commenced an investigation into the death of Samantha MacDonald, 20 years, born 12t August 1995. The investigation concluded at the end of the inquest on Monday 25th January, 2016. The conclusion of the inquest was Suicide

Circumstances of the death

On the 25th October 2015 Samantha Jane MacDonald jumped from the window of her bedroom on the 14th floor of student accommodation at Eddie Coleman Court, Salford_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0036
Date of report: 5 February 2016
Coroner: Jennifer Leeming
Coroner area: Manchester (West)

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: 1 Apr 2016 (estimated).

Sent to

Campus Living Villages

Department for Education

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.