Dear Mr Pears Re: Inquest touching_the death of Stephen James Lawson write further to your letter dated 13 August 2018 in connection to the unfortunate death of the above named individual, which references the Regulation 28 Report you issued in your role as Acting Senior Coroner for Bedfordshire & Luton. understand from the Regulation 28 Report that you have commenced an Investigation and have not yet concluded the Inquest: Background The Council owns a variety of car parks for use by residents and visitors to Bedford Borough, they are provided at convenient locations for work-place parking or somewhere to park whilst shopping in Bedford town centre. The car parks comprise of a mixture of multi-storey car parks (MSCPs) and open surface car parks. The Council is fully aware of its responsibility as the owner of four MSCPs within Bedford town, and the Council takes its role seriously as a provider of car parking services to users of its premises_ Staff from the Parking Services Team regularly carry out buildinglworkplace inspection of all MSCPs that are controlled by the Council; This involves the regular assessment of the physical structure and fabric of the buildings, along with the assessment of hazards and risks that would be relevant to the health and safety of those parking and accessing vehicles in MSCPs. As such, the Council has a comprehensive approach concerning safety, security and risk management in relation to managing the MSCPs that are under its control. Please note that all levels of all MSCPs are proactively patrolled on an hourly_basis by Civil Enforcement Officers (CEOs) , part of their remit is to visually assess the areas and take action regarding unauthorised access or activities that may be taking place; part of this visual assessment includes taking action and raising the alarm where a member of the public may be behaving in a manner which gives cause for concern_ Philip Simpkins Chief Executive Borough Hall, Cauldwell Street, Bedford MK42 9AP DX 117105 Bedford 4 Phone (01234) 718202 Fax (01234) 718201 Web WWWW bedford gov.uk Minicom (01234) 221827 "GORONER BEDFORD OCT z018 OFFICE DSHiREE AND!

On the rare occasion that the alarm is raised regarding the behaviour of a member of the public, there is a comprehensive MSCP Emergency Procedure that CEOs, Control Room staff and Manager[Team Leaders follow regarding the Council's response to dealing with the situation_ The procedure covers the main actions that must be carried out where a situation exists that requires an 'emergency response' this includes calling the blue light services (Police, Fire, Ambulance) , the closure of' the building, the management of the area and communication with other users of the building: Part of the management arrangements of the MSCPs within the Borough ensures that all levelsldecks of the MSCPs are covered by a comprehensive CCTV surveillance system. CCTV is proactively used to monitor the locations for a range of issues that might be relevant; one of which early sighting and raising the alarm regarding members of the public who behave in a concerning manner near to the perimeter walls of the car park Historically the Council has invested in the safety and security of its MSCPs adopting reasonable and risk based approach, utilising competent professionals and contractors to improve the facilities on offer_ Examples of the risk based approach adopted and the measures implemented as a result can be seen at Appendix B, Images 3 to 8. The Council also undertakes regular annual investment regarding the provision of car parking facilities within the town centre. Periodically the Council also invests in various capital investment schemes to improve and upgrade the facilities on offer; these improvements often relate to safety and security of the car parks in order to provide a well-managed environment for visitors to use_ Recent examples include a full refurbishment of Allhallows MSCP. The work included new improved CCTV across all areas of the car park, updated communication systems, upgraded lighting and fire control systems This work took place in 2015 and won an award the British Parking Association as the Best Car Park Refurbishment in 2015. In addition to this last year all the MSCPs received additional CCTV cameras on the parking levels and in the stairwells, new reactive lighting was installed throughout all MSCPs and new lifts were installed at Lurke Street Car Park: As stated earlier CEOs routinely inspect the car parks and at least once an hour AII New recruits receive a Level 2 City & Guilds training in Parking Enforcement: As consequence Bedford Borough Council's MSCPs have held in excess of five years the British Parking Associations 'Park Mark' which recognises quality and safety within its car parks, in addition to this for the last two years the MSCPs have also held 'Disability Park' award. Requlation 28 Report In reference to section 5 of your report; Coroner's Concerns, the situation(s) you refer to have been reviewed by officers of the Council and am now in a position to address each in turn and provide further narrative on the issue_ In addition to being lifts , from the point

my substantive responses below have also included an Action Plan regarding the points identified from your report so that the Council is able to consider all issues arising from this unfortunate incident (see Appendix A) have also provided relevant information in Appendix B regarding your Report which trust you will consider useful.
1) This is not the first person to have jumped from this car park According to emergency calls for the previous five years, a summary of incidents relating to potential suicides in what can be complex circumstances has been provided below MSCP Date Brief Description Lurke Street Feb 2015 Male threatened to jump_police negotiators attended Jan 2017 Female threatened to jump, talked down by friend and presented at hospital,Crisis Team involved Male and friend presented at hospital voluntarily after 2017 friend talked down male Male threatened to jump, police attended and male 2017 diagnosedlsectioned with mental health needs Jan 2018 Male threatened to jump, talked down by police and attended hospital,_Crisis Team involved Jan 2018 Male threatened to jump , police attended and male diagnosed/sectioned with mental health needs River Street No Reports Queen Jan 2018 Intoxicated male threatened to jump, talked down by Street CEOs, police took to male mental health team at hospital Allhallows Intoxicated male threatened to jump, talked down by 2014 police negotiator; police took to male hospital for mental health assessment 2016 Female threatened to jump, police officers talked her down Jan 2017 Male threatened to jump, police officers attended and intervened
2) It is surprisingly easy to access to the external barrier wall The external barrier walllperimeter wall on each deck of Lurke Street MSCP is flanked by a steel crash barrier and steel caging (see Appendix B, Image 1 and 2). This steel crash barrier and caging arrangement serves a dual purpose of protecting the structural integrity of the perimeter walls of the car park from damage that may be caused by vehicular collision and restricting the proximity that pedestrians are able to gain to the perimeter wall of each deck The original design of each deck of Lurke Street MSCP includes a 'reveal' along sections of the perimeter walls (see Appendix B, Image 2). This reveal is likely to have been designed as an architectural feature of the building which increased key May May May July gain

visibilityllight onto each deck of the building, whose walls are constructed from pre- cast concrete At the highest point the perimeter walls measure 145Omm in height At their lowest point; within the reveal of the section of wall, the perimeter walls measure 950mm in height: The height of the steel caging is 1150mm at all points of the perimeter wall and thus exceeds the height of the wall along the length of the reveals Save in a construction context;, there are no prescriptive dimensions provided for the height of guard rails, however should be of sufficient dimension to ensure a person cannot fall through or over them. In the absence of any standards, HSE operational guidance suggests that guard rail heights in non-construction context should be a minimum of 950mm, and goes on to say that a wall could be considered as a guard rail: protection below this height should be justified on the basis of a risk assessment. For buildings; factories, warehouses, offices, public buildings, retail premises sufficient dimensions for guard rails or similar barriers will be achieved by complying with the Building Regulations which require guard rails of a minimum height of 110Omm, avoiding the use of horizontal rails. As a result of the recent incident concerning Mr Lawson a visual audit of all MSCPs was carried out on 31 August 2018. At the time of the audit the condition of the steel barriers was considered to be in good condition overall, however it was noted in certain places that damage had occurred at a small number of locations where protective plates had become looselmissing on the corner junctions of the steel barriers, any repairs will be addressed as part of planned remedial works (see Action Point 1 beiow)_
3) If a person accesses the space between the crash barrier and the external wall; the crash barrier can be used as a step to cross the external wall It would be ergonomically difficult for a person to access the space between the steel barrier and the perimeter wall on each deck of Lurke Street MSCP as the steel caging encloses the vehicular crash barrier. However; if a person were so minded to climb inbetween the perimeter wall and the steel caged barrier; then the structure might possibly provide a sufficient foothold for a person to raise their body above the height of the perimeter wall, thereby exposing themselves to the hazard of falling from height. It would require a determined and physical effort to climb over the caged barrier and then use it as a foothold.
4) There are very few 'Samaritans' signs, and these generally are only visible if a pedestrian is exiting the car There is some signage located within the MSCPs that promote the services of the Samaritans for persons that may need to use their confidential counselling services_ Nevertheless, requested that a full signage audit be carried out as is set out below they Any etc, park have

Generally As a result of this incident; have requested officers to out actions as detailed in the Action Plan set out in Appendix A By way of an explanation of the various points in that plan: Action Point 1 In response to the findings of the audit carried out on 31st August 2018 have instructed that all steel barriers and steel caging arrangements in all car parks are assessed by a competent professional, and where repairs be identified these repairs will be carried out using a risk based approach to any matters that are identified, focussing on areas and locations that have a higher use, accesslegress etc_ Given the open nature of these buildings there is an element of wear and tear that is addressed as and when required. It is envisaged that any works identified will be completed within three months of the date of this letter Action Point 2 have also instructed that each of the four MSCPs is risk assessed as part of the annual premiseslworkplace inspection process employed by the Council as part of its ongoing legal duties These premiseslworkplace risk assessments will be completed by 31 October 2018. Action Point 3 The MSCP Emergency Procedure will be reviewed and all relevant staff within Parking Services receive refresher training and instruction regarding the appropriate response required should an emergency incident occur: This training and instruction will be completed with all relevant staff by 31 October 2018 Action Point 4 have instructed that a full signage audit is carried out in order review all signage types within the MSCPs, including Samaritans, in order that the Council can be confident that it complies with any duties to identify existing hazards, to the users of the MSCPs_ It is anticipated that any works identified will be completed within two months of the date of this letter. trust that this response addresses points and hope that the information supplied addresses the matters raised in your report If you require any further information then please do not hesitate to get in touch