Sylvia Price
PFD Report
Partially Responded
Ref: 2023-0009Deceased
1 of 3 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 3
56-Day Deadline
2 Mar 2023
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
the MATTERS OF CONCERN as follows. –
Evidence was heard that Sylvia had underlying medical issues that required an easily accessible toilet facility.
The jury concluded that the lack of appropriate signage, to readily identify an easily accessible toilet facility, was a directly contributory factor leading to Sylvia’s death.
The Local Authority Food and Safety Officer who investigated this case identified no other contributing factors, with the stairs themselves meeting building and safety regulations.
The officers report contained only one recommendation for the premises owner, which was the provision of more adequate signage.
However, the officer stated in evidence that there was no statutory power to enforce the provision of such signage, and should a premises owner wish to ignore such a recommendation, they could (it is acknowledged that the premise owner in this case has put new signage in place). In addition, current building regulations do not require any such signage to be fitted into new buildings.
The court was informed that the provision of adequate accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use, but as detailed above there is no requirement for these facilities to be clearly identified with appropriate signage.
As a failure to provide adequate signage was found to be a contributing factor in this case, and there is no enforceable requirement that such signage should be provided, I am concerned further deaths may occur in other public access buildings, should similar circumstances arise in the future.
Evidence was heard that Sylvia had underlying medical issues that required an easily accessible toilet facility.
The jury concluded that the lack of appropriate signage, to readily identify an easily accessible toilet facility, was a directly contributory factor leading to Sylvia’s death.
The Local Authority Food and Safety Officer who investigated this case identified no other contributing factors, with the stairs themselves meeting building and safety regulations.
The officers report contained only one recommendation for the premises owner, which was the provision of more adequate signage.
However, the officer stated in evidence that there was no statutory power to enforce the provision of such signage, and should a premises owner wish to ignore such a recommendation, they could (it is acknowledged that the premise owner in this case has put new signage in place). In addition, current building regulations do not require any such signage to be fitted into new buildings.
The court was informed that the provision of adequate accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use, but as detailed above there is no requirement for these facilities to be clearly identified with appropriate signage.
As a failure to provide adequate signage was found to be a contributing factor in this case, and there is no enforceable requirement that such signage should be provided, I am concerned further deaths may occur in other public access buildings, should similar circumstances arise in the future.
Responses
Response received
View full response
• Rt Hon Michael Gove MP Secretary of State for Levelling up, Housing and Communities Department for Levelling Up, Minister for Intergovernmental Relations 2 Marsham Street Housing & Communities London SW1P 4DF
Nigel Parsley HM Senior Coroner for Suffolk Beacon House Whitehouse Road Ipswich, Suffolk IP1 5PB
l°Jft., June 2023 Inquest into the death of Sylvia Frances Price: Regulation 28 report Thank you for your investigative report of 4 January into the death of Sylvia Frances Price, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was submitted to the Minister of State for Disabled People Health & Work; and the Minister of State for Business, Energy & Industrial Strategy. I am responding to you as the finding of the inquest concerned signage and Building Regulations. Building Regulations and the statutory guidance supporting them, Approved Documents, sit within my area of responsibility. I would like to offer my sincere condolences to Ms Price's family and friends and also acknowledge the professionalism of health workers who cared for her at Ipswich Hospital. You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. In this letter, I set out the work currently underway by officials in my department and at the Building Safety Regulator to update Building Regulations regarding toilet provision and to prepare statutory guidance in a new Approved Document. There will be a period of public consultation to supplement evidence already held by the department. I can assure you that I will consider findings that arise and what changes are necessary to reduce the risk of similar incidents in the future. At the inquest, evidence was heard that Ms Price had underlying medical issues that required an easily accessible toilet facility. The jury concluded that the lack of appropriate signage to readily identify an easily accessible toilet facility was a contributory factor leading to Ms Price's death. The local authority officer who investigated this case identified no other contributing factors and noted that the stairs themselves met building and safety regulations. The officer's report contained only one recommendation for the premises owner, relating to provision of more adequate signage, which has since been installed. Your report noted the officer stated in evidence that there was no statutory power to enforce the provision of such signage, and should a premises owner wish to ignore such a recommendation, they could.
The point was also made that there was no requirement for signage of this nature in the building regulations for new buildings, so it was not clear what form such signage should take even if an enforcement officer decided that it was necessary. I therefore consider it important to highlight what legislation applies to new buildings being constructed and what applies to existing buildings. New Buildings Building Regulations and Approved Documents for new build and construction You noted in your report that provision of adequate accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use. For new build, or where re design or major refurbishment of existing buildings is anticipated, work must comply with the Building Regulations. The Approved Documents provide statutory guidance on how to achieve compliance. The Building Regulations and Approved Documents ensure that minimum standards for size, space and materials are incorporated into new buildings. Approved Document M ('Access to and use of buildings - Volume 2: Buildings other than dwellings') is the relevant statutory guidance in such a case. It sets out design considerations for toilet accommodation (including wheelchair accessible toilets) at paragraphs 5.5 to 5.10 and includes guidance on other provisions, e.g. support rails and a wash basin. Additionally, building design professionals are directed to BS8300 which covers provision of signs and information. The Building Regulations apply to new design and construction; they are not retrospective. A Building Control Body (including local authority Building Control Officers and Approved Inspectors) will make sure that building regulations are followed in new buildings or when building works (as defined in the Building Regulations 2010) are carried out. They cannot require an existing building where no building works are completed to be modified or change its layout. Technical changes to Building Regulations and Approved Documents The Government's call for evidence on toilet provision for men and women ended in February 2021. Following that, in July last year, the Government set out its intention to launch a technical consultation on formal changes to the Building Regulations and Approved Documents. We are preparing the consultation document now with a view to publication later this summer. We will seek views on the design and range of toilet provision, so that we can prepare new statutory guidance. We will draw on evidence from commissioned research to inform possible design suggestions for a variety of non-residential toilet facilities including wheelchair-accessible toilets, toilet signage and labelling. I will ensure that a review of Approved Document M is coherent with the new statutory guidance we will prepare on toilet provision . We will also take steps to ensure that signage provision is given appropriate prominence in statutory guidance so that it may be readily understood by Building Control Officers. Existing Buildings Whilst our work on updating the relevant building regulations will address the fundamental issue of what signage should be provided in new buildings, there are other areas of existing legislation which support appropriate toilet provision for disabled persons which are therefore relevant in this case.
Health and safety legislation and enforcement In workplaces (including hotels), a need for signage to mitigate risks (based on principles of prevention) would normally be identified as part of routine management risk assessment procedures; the relevant legislation is the Health and Safety at Work Act 197 4, the Health and Safety (Enforcing Authority) Regulations 1998, and the Management of Health and Safety at Work Regulations 1999. Health and safety legislation requires every employer to make a suitable and sufficient assessment of the risks to the health and safety of employees and persons who are not in the employer's employment but where risks might arise out of or in connection with their business. Local authorities are responsible for enforcement relating to premises in their area. Equality Act 2010: reasonable adjustments to existing premises The Equality Act 2010 provides protections for people with disabilities who may encounter difficulties in accessing existing premises. Service providers are under an anticipatory duty to make reasonable adjustments to enable customers with disabilities to use their premises and facilities. An obligation to make reasonable adjustments is continuous. The Equality and Human Rights Commission notes that if a disabled person wants to use an organisation's services but encounters barriers, then the organisation needs to think about reasonable adjustments whether or not any adjustments have already been made. In premises open to the public, this may involve making changes where barriers have been created by the physical features of those premises, or providing auxiliary aids or auxiliary services. In this and similar cases, providing appropriate signage to readily identify an easily accessible toilet facility could be considered an auxiliary aid. Building Safety Regulator Finally, we have introduced a more stringent regulatory regime led by the Building Safety Regulator. The Building Safety Regulator has responsibilities for overseeing the safety of all buildings, including identifying patterns of regulatory failure and making recommendations for improving standards. This will drive continuous improvement in buildings technology and construction techniques. I have sent your report to who has taken up the role of Director of Building Safety at the Building Safety Regulator. The Government is committed to ensuring a safe built environment for all. Thank you, once again, for your report. Rt Hon Michael Gove MP Secretary of State for Levelling up, Housing and Communities Minister for Intergovernmental Relations
Nigel Parsley HM Senior Coroner for Suffolk Beacon House Whitehouse Road Ipswich, Suffolk IP1 5PB
l°Jft., June 2023 Inquest into the death of Sylvia Frances Price: Regulation 28 report Thank you for your investigative report of 4 January into the death of Sylvia Frances Price, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was submitted to the Minister of State for Disabled People Health & Work; and the Minister of State for Business, Energy & Industrial Strategy. I am responding to you as the finding of the inquest concerned signage and Building Regulations. Building Regulations and the statutory guidance supporting them, Approved Documents, sit within my area of responsibility. I would like to offer my sincere condolences to Ms Price's family and friends and also acknowledge the professionalism of health workers who cared for her at Ipswich Hospital. You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. In this letter, I set out the work currently underway by officials in my department and at the Building Safety Regulator to update Building Regulations regarding toilet provision and to prepare statutory guidance in a new Approved Document. There will be a period of public consultation to supplement evidence already held by the department. I can assure you that I will consider findings that arise and what changes are necessary to reduce the risk of similar incidents in the future. At the inquest, evidence was heard that Ms Price had underlying medical issues that required an easily accessible toilet facility. The jury concluded that the lack of appropriate signage to readily identify an easily accessible toilet facility was a contributory factor leading to Ms Price's death. The local authority officer who investigated this case identified no other contributing factors and noted that the stairs themselves met building and safety regulations. The officer's report contained only one recommendation for the premises owner, relating to provision of more adequate signage, which has since been installed. Your report noted the officer stated in evidence that there was no statutory power to enforce the provision of such signage, and should a premises owner wish to ignore such a recommendation, they could.
The point was also made that there was no requirement for signage of this nature in the building regulations for new buildings, so it was not clear what form such signage should take even if an enforcement officer decided that it was necessary. I therefore consider it important to highlight what legislation applies to new buildings being constructed and what applies to existing buildings. New Buildings Building Regulations and Approved Documents for new build and construction You noted in your report that provision of adequate accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use. For new build, or where re design or major refurbishment of existing buildings is anticipated, work must comply with the Building Regulations. The Approved Documents provide statutory guidance on how to achieve compliance. The Building Regulations and Approved Documents ensure that minimum standards for size, space and materials are incorporated into new buildings. Approved Document M ('Access to and use of buildings - Volume 2: Buildings other than dwellings') is the relevant statutory guidance in such a case. It sets out design considerations for toilet accommodation (including wheelchair accessible toilets) at paragraphs 5.5 to 5.10 and includes guidance on other provisions, e.g. support rails and a wash basin. Additionally, building design professionals are directed to BS8300 which covers provision of signs and information. The Building Regulations apply to new design and construction; they are not retrospective. A Building Control Body (including local authority Building Control Officers and Approved Inspectors) will make sure that building regulations are followed in new buildings or when building works (as defined in the Building Regulations 2010) are carried out. They cannot require an existing building where no building works are completed to be modified or change its layout. Technical changes to Building Regulations and Approved Documents The Government's call for evidence on toilet provision for men and women ended in February 2021. Following that, in July last year, the Government set out its intention to launch a technical consultation on formal changes to the Building Regulations and Approved Documents. We are preparing the consultation document now with a view to publication later this summer. We will seek views on the design and range of toilet provision, so that we can prepare new statutory guidance. We will draw on evidence from commissioned research to inform possible design suggestions for a variety of non-residential toilet facilities including wheelchair-accessible toilets, toilet signage and labelling. I will ensure that a review of Approved Document M is coherent with the new statutory guidance we will prepare on toilet provision . We will also take steps to ensure that signage provision is given appropriate prominence in statutory guidance so that it may be readily understood by Building Control Officers. Existing Buildings Whilst our work on updating the relevant building regulations will address the fundamental issue of what signage should be provided in new buildings, there are other areas of existing legislation which support appropriate toilet provision for disabled persons which are therefore relevant in this case.
Health and safety legislation and enforcement In workplaces (including hotels), a need for signage to mitigate risks (based on principles of prevention) would normally be identified as part of routine management risk assessment procedures; the relevant legislation is the Health and Safety at Work Act 197 4, the Health and Safety (Enforcing Authority) Regulations 1998, and the Management of Health and Safety at Work Regulations 1999. Health and safety legislation requires every employer to make a suitable and sufficient assessment of the risks to the health and safety of employees and persons who are not in the employer's employment but where risks might arise out of or in connection with their business. Local authorities are responsible for enforcement relating to premises in their area. Equality Act 2010: reasonable adjustments to existing premises The Equality Act 2010 provides protections for people with disabilities who may encounter difficulties in accessing existing premises. Service providers are under an anticipatory duty to make reasonable adjustments to enable customers with disabilities to use their premises and facilities. An obligation to make reasonable adjustments is continuous. The Equality and Human Rights Commission notes that if a disabled person wants to use an organisation's services but encounters barriers, then the organisation needs to think about reasonable adjustments whether or not any adjustments have already been made. In premises open to the public, this may involve making changes where barriers have been created by the physical features of those premises, or providing auxiliary aids or auxiliary services. In this and similar cases, providing appropriate signage to readily identify an easily accessible toilet facility could be considered an auxiliary aid. Building Safety Regulator Finally, we have introduced a more stringent regulatory regime led by the Building Safety Regulator. The Building Safety Regulator has responsibilities for overseeing the safety of all buildings, including identifying patterns of regulatory failure and making recommendations for improving standards. This will drive continuous improvement in buildings technology and construction techniques. I have sent your report to who has taken up the role of Director of Building Safety at the Building Safety Regulator. The Government is committed to ensuring a safe built environment for all. Thank you, once again, for your report. Rt Hon Michael Gove MP Secretary of State for Levelling up, Housing and Communities Minister for Intergovernmental Relations
Action Should Be Taken
In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify.
Report Sections
Investigation and Inquest
On 9th December 2021 I commenced an investigation into the tragic death of-Sylvia Frances PRICE The investigation concluded at the end of the inquest on 8th December 2022. The conclusion of the inquest was that:- Sylvia Price, died as the result of an accidental death The medical cause of death was confirmed as: 1a Aspiration pneumonia 1b Intracerebral, subdural and extradural haemorrhages 2 Cervical and thoracic spine fractures
Circumstances of the Death
Sylvia Frances Price died on the 4th December 2021 at 0915 am, at Ipswich Hospital, Heath Road, Ipswich. Sylvia attended Ufford Park Hotel and Spa on the 30th November 2021 for a meal. Prior to leaving the hotel, Sylvia went to use the toilet facilities. The closest toilet facilities were located down a flight of stairs. Sylvia fell down this flight of stairs. No signage was in place in the vicinity, that would have indicated the availability of an accessible toilet on the same level as an alternative option.
The injuries she sustained as a result of the fall were extensive, and led to Sylvia being admitted to Ipswich Hospital. Whilst being treated for her injuries at Ipswich Hospital, Sylvia developed aspiration pneumonia which was the medical cause of her death.
The injuries sustained in the fall, cerebral haemorrhages and spinal injuries, were contributing factors to her death.
The injuries she sustained as a result of the fall were extensive, and led to Sylvia being admitted to Ipswich Hospital. Whilst being treated for her injuries at Ipswich Hospital, Sylvia developed aspiration pneumonia which was the medical cause of her death.
The injuries sustained in the fall, cerebral haemorrhages and spinal injuries, were contributing factors to her death.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Review CCTV monitoring SIA licence requirements
Manchester Arena Inquiry
Unregulated recreation safety
Establish standard for event healthcare services
Manchester Arena Inquiry
Unregulated recreation safety
Mandatory Ambulance Liaison Officer at events
Manchester Arena Inquiry
Unregulated recreation safety
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.