Lisa Jane Clayton
PFD Report
Unknown
Ref: 2013-0309
No published response · Over 2 years old
Response Status
Responses
0
56-Day Deadline
18 Apr 2014
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
and being and five park
1) The wall surrounding the 7ih floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large_ The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall; particularly when combined with the barrier/bumper mentioned at point 1_
3) The walllrails are an insufficient deterrentlpreventative measure_
4) The level and extent of CCTV monitoring particularly of the 7ih floor; which is usually coned off to prevent public usage (save for at the busiest times) is insufficient The building has 24 hour security officers in attendance and it is accepted that at night; the building is physically secured_ However; day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be_in terms of keeping a check on who is accessing a (top) floor that has been coned off to the general public There has been no allocatedlfixed camera covering or monitoring access and usage of the 7h floor:
5) The staffing levels within the security control room are insufficient There is one guard, watching 6 screens, covering 40 cameras In addition, the same is required to complete paperwork and Iiaise_ assist and CO-ordinate security colleagues 'on the ground' Even at the busiest times, only one guard is on duty in the control room_
6) There have been previous acts and attempts by others to take their own life, at the same location_ Her Majesty's Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles_ In addition; the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same Despite this, little direct action has (or appears to have) been taken:
1) The wall surrounding the 7ih floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large_ The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall; particularly when combined with the barrier/bumper mentioned at point 1_
3) The walllrails are an insufficient deterrentlpreventative measure_
4) The level and extent of CCTV monitoring particularly of the 7ih floor; which is usually coned off to prevent public usage (save for at the busiest times) is insufficient The building has 24 hour security officers in attendance and it is accepted that at night; the building is physically secured_ However; day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be_in terms of keeping a check on who is accessing a (top) floor that has been coned off to the general public There has been no allocatedlfixed camera covering or monitoring access and usage of the 7h floor:
5) The staffing levels within the security control room are insufficient There is one guard, watching 6 screens, covering 40 cameras In addition, the same is required to complete paperwork and Iiaise_ assist and CO-ordinate security colleagues 'on the ground' Even at the busiest times, only one guard is on duty in the control room_
6) There have been previous acts and attempts by others to take their own life, at the same location_ Her Majesty's Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles_ In addition; the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same Despite this, little direct action has (or appears to have) been taken:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you (ANDIOR your organisation) have the power to take such action
Report Sections
Investigation and Inquest
On 04/07/2012 the Senior Coroner commenced an investigation into the death of Lisa Jane CLAYTON, then aged 44 Years The investigation was concluded at the end of the inquest on 15/11/2013. The conclusion of the inquest was the deceased took her own life whilst the balance of her mind was disturbed: The medical cause of death Ia) multiple Injuries
Circumstances of the Death
Ms Clayton had been suffering serious significant mental health issues following the birth of her second child in late 2010 . She was cared for by both inpatient and community mental health teams and received significant care and support from her family and friends _ She had been diagnosed with a severe form of clinical depression_ She had attempted to self harm on previous occasions and had subsequently been hospitalised as a 'voluntary patient' . On the evidence, it appeared that ideation was an ever present risk On the 27/h June 2012 she went missing from home, within a very short timeslot of less than minutes (between her mother leaving and her mother's partner arriving) Police were contacted. At around the same time Police were also called to attend the Spindles shopping centre car park. At around 15.20, Ms Clayton was found at the foot of The Spindles car park, at the kerbside When police subsequently examined CCTV security recordings; Ms Clayton was initially noted to have entered the Spindles car park by the 'out' barriers A short while later; she was captured on the wall surrounding the floor of the car She was seen to 'shuffle to the edge and disappeared:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.