Source · Prevention of Future Deaths
Thomas Combeer
Ref: 2026-0407
Date: 7 Aug 2026
Coroner: Susan Ridge
Area: Surrey
56-day deadline: 2 Oct 2026 (stated in the report)
Responses identified: 0 of 2
0 responses identified · 2 indexed addressees
Response deadline: 2 October 2026 (stated in the report).
Coroner's concerns
Coroner’s Concerns (source excerpt)
In my opinion, there is a risk that future deaths could occur unless action is taken. a. The multi-storey car parks in Guildford owned by Guildford Borough Council present a safety risk to the public (including children) of falling and that there are insufficient measures in place to prevent suicide b. More widely, current Building...
View full coroner's concerns
In my opinion, there is a risk that future deaths could occur unless action is taken. a. The multi-storey car parks in Guildford owned by Guildford Borough Council present a safety risk to the public (including children) of falling and that there are insufficient measures in place to prevent suicide b. More widely, current Building Regulations guidance and the British Standards guidance may conflict about the height of guarding.
c. Building Regulations are not retrospective and therefore older multi-storey car parks built before Building Regulations 2010, Guidance: Approved Document K came into force in 2013 may not have or are not required to have the current edge protection height of 110cms.
The court heard that in relation to Guildford Borough Council multi-storey car parks: a. There have been at least 4 deaths from York Road Car Park and one other multi-storey car park in Guildford since 2020. Although a report in 2020 recommended safety measures including increased guard height, the majority of the recommendations were not implemented for cost reasons.
b. The public, including children, have unfettered access to those car parks, day and night.
c. The higher levels of the York Road Car Park is popular with skateboarders because of the higher ceilings d. The guard edge at the York Road Car Park is 95 cms from the bottom of the parapet wall to the top of the handrail.
e. The guard edge does not meet the minimum height (110cm) required under Approved Document K to Building Regulations.
f. Security staff are not located on individual car park premises at night but at a central control office from which they operate patrols g. Guildford multi-storey car parks have limited CCTV coverage.
And that in relation to multi-storey car parks more widely; a. There is a potential conflict between Building Regulations 2010, Guidance: Approved Document K and British Standards, Code of Practice for barriers in and about buildings. It is not clear from the guidance and standards where the start point for the measurement of the barrier is to be taken, whether floor level or top of parapet.
b. Multi-storey car parks built before Building Regulations Approved Document K (Section 2) came into force in 2013 may not meet the current guard height.
c. Building Regulations are not retrospective and therefore older multi-storey car parks built before Building Regulations 2010, Guidance: Approved Document K came into force in 2013 may not have or are not required to have the current edge protection height of 110cms.
The court heard that in relation to Guildford Borough Council multi-storey car parks: a. There have been at least 4 deaths from York Road Car Park and one other multi-storey car park in Guildford since 2020. Although a report in 2020 recommended safety measures including increased guard height, the majority of the recommendations were not implemented for cost reasons.
b. The public, including children, have unfettered access to those car parks, day and night.
c. The higher levels of the York Road Car Park is popular with skateboarders because of the higher ceilings d. The guard edge at the York Road Car Park is 95 cms from the bottom of the parapet wall to the top of the handrail.
e. The guard edge does not meet the minimum height (110cm) required under Approved Document K to Building Regulations.
f. Security staff are not located on individual car park premises at night but at a central control office from which they operate patrols g. Guildford multi-storey car parks have limited CCTV coverage.
And that in relation to multi-storey car parks more widely; a. There is a potential conflict between Building Regulations 2010, Guidance: Approved Document K and British Standards, Code of Practice for barriers in and about buildings. It is not clear from the guidance and standards where the start point for the measurement of the barrier is to be taken, whether floor level or top of parapet.
b. Multi-storey car parks built before Building Regulations Approved Document K (Section 2) came into force in 2013 may not meet the current guard height.
Report sections
Investigation and inquest
On 20 March 2025, an investigation commenced into the death of Thomas Andrew James Combeer aged 17 years and concluded on 30 July 2026.
The medical cause of death was Head and Torso Injuries
How, when and where:
Thomas Andrew James COMBEER died in the early hours of 8 March 2025 at York Road Car Park, Guildford in Surrey from head and torso injuries having taken steps to fall from [REDACTED] the car park for reasons that remain unknown. Shortly before his death Mr Combeer sent two farewell messages, one to his family and one to his friends.
Conclusion: Suicide
The medical cause of death was Head and Torso Injuries
How, when and where:
Thomas Andrew James COMBEER died in the early hours of 8 March 2025 at York Road Car Park, Guildford in Surrey from head and torso injuries having taken steps to fall from [REDACTED] the car park for reasons that remain unknown. Shortly before his death Mr Combeer sent two farewell messages, one to his family and one to his friends.
Conclusion: Suicide
Circumstances of the death
At around 01:50 hours on 8 March 2025 Thomas walked into York Road Car Park in Guildford. He had unfettered access to the car park which was open 24 hours. Thomas walked up [REDACTED] the car park, sent two messages, one to his family and one to his friends and then at 0155 hours either [REDACTED] drop to his death.
There were no suspicious circumstances and toxicology revealed alcohol levels below the current legal driving limit and no drugs. His jacket, tablet and keys were found on the [REDACTED]
There were no suspicious circumstances and toxicology revealed alcohol levels below the current legal driving limit and no drugs. His jacket, tablet and keys were found on the [REDACTED]
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
- I can confirm I have sent the report to
- 1.Chief Executive British Parking Association
- SIGNATURE Susan Ridge Assistant Coroner for Surrey
- Thomas Combeer
- Prevention of future deaths report
- 2026
- 0407_PublishedDownload
Similar PFD reports Shared signals
Responses identified
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Oct 2026 (stated in the report).
Sent to
- Chief Executive, Guildford Borough Council
- Secretary of State, Ministry of Housing, Communities and Local Government
Source links
Data: judiciary.uk.