Stephen Page
PFD Report
Partially Responded
Ref: 2026-0046
Coroner's Concerns (AI summary)
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities for intervention.
View full coroner's concerns
The MATTER OF CONCERN is as follows. - (1) Written evidence from a senior member of staff at MAPP (who provide security management at Hempstead Valley) set out that there is an electronic sensor system in place The evidence was that, "When the sensor beam is broken, the corresponding CCTV camera automatically moves to the activation point and displays a visual alert marked 'Alarm'. The camera remains focused on the area to allow for monitoring if an operator is present." The investigating officer from Kent Police, said in their statement, "This 'alarm' is visual only and displays for a few seconds. Due to the number of screens, this could have been easily missed by the CCTV operator." For the avoidance of doubt, the evidence suggested that the alarm system was working and operational on 17 August 2025. Further, there was no evidence of a delayed response in this particular instance. However, it is not difficult to envisage (particularly given that there is no audible alarm) a situation in which a triggering of the 'alarm' could be missed and an opportunity for staff to intervene being lost.
Responses
Action Taken
MAPP has taken action by implementing an audible alarm system, instructing enhancement of physical perimeter safety measures (completion April 2026), and arranging suicide prevention awareness training. (AI summary)
MAPP has taken action by implementing an audible alarm system, instructing enhancement of physical perimeter safety measures (completion April 2026), and arranging suicide prevention awareness training. (AI summary)
View full response
Dear Sir We write in response to the 'Regulation 28 Report to Prevent Future Deaths’ dated 18 December 2025, received on 28 January 2026. MAPP manage the building on behalf of our client and therefore we are responding on behalf of the centre manager ( ) whom you also address the Report to. The matters identified in the Report have been considered. In response we can confirm that action has been taken in respect of:
• An audible alarm system linked to on-site security arrangements in the relevant area.
• Instruction to enhance the physical perimeter safety measures (completion of all physical measures will be April) 2026. » Action has been taken to arrange for suicide prevention awareness training to be delivered on site by an external provider. These matters are being addressed through established management and governance processes. 180 Great Portland Street (please change these details if needed) London W1W 5QZ 020 7908 5500 info@wearemapp.com MAPP is the trading name of MAPP (Property Management) Limited 180 Great Portland Street, London W1W 5QZ Company reg number. 03602713 wearemapp.com
MAPP We thank you for your correspondence in this matter and our thoughts are with the family during this difficult time.
• An audible alarm system linked to on-site security arrangements in the relevant area.
• Instruction to enhance the physical perimeter safety measures (completion of all physical measures will be April) 2026. » Action has been taken to arrange for suicide prevention awareness training to be delivered on site by an external provider. These matters are being addressed through established management and governance processes. 180 Great Portland Street (please change these details if needed) London W1W 5QZ 020 7908 5500 info@wearemapp.com MAPP is the trading name of MAPP (Property Management) Limited 180 Great Portland Street, London W1W 5QZ Company reg number. 03602713 wearemapp.com
MAPP We thank you for your correspondence in this matter and our thoughts are with the family during this difficult time.
Sent To
Response Status
Linked responses
1 of 3
56-Day Deadline
12 Feb 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 19 August 2025 I commenced an investigation into the death of Stephen Paul PAGE, aged 70 years at the time of his death. The investigation concluded at the end of the inquest heard by me on 17 December 2025. The conclusion of the inquest was: Suicide The medical cause of death was: 1a Ascending Aortic Wall Dissection With Haemothorax And Neck Fracture
Circumstances of the Death
On the morning of 17 August 2025, Stephen Page drove alone to the multi-storey car park of Hempstead Valley Shopping Centre in Gillingham. . Despite efforts to treat Mr Page, a paramedic verified the fact of his death on scene at 10:42 on 17 August 2025. Mr Page died as a result of the traumatic injuries he sustained. He had intended his actions to bring about his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.