Response to Regulation 28 Prevention of Future Deaths Report

Executive Summary East Suffolk Council notes the coroner’s findings.

In this document, we address the areas of concern and describe steps already taken and considerations for the future.

In light of the incident, and prior to the coroner’s conclusion being published, East Suffolk Council reviewed its risk assessments to ensure risks relating to all users, including those with mobility scooters, were considered. The result of those risk assessments forms the basis of the response below.

Coroner’s Concerns
• Evidence was heard that the height of drop from the edge of the promenade to the sand at the locaƟon John fell, whilst on his mobility scooter, was approximately 5 feet.
• The court was told that, at a number of locaƟons, the height from the edge of the promenade to the sand was prone to change, and a system was in place to monitor this. It was however, acknowledged, that unusual high Ɵde condiƟons, and/or weather acƟvity could significantly change the drop height in a short period of Ɵme.
• Evidence heard that at high-risk locaƟons, such as areas with persistent long drops, drops onto concrete, or drops onto rock sea defences, permanent barriers were installed.
• It was acknowledged that individuals on mobility scooters were known to regularly access and use the promenade. Due to the demographics of the local area it was acknowledged that the use of mobility scooters on the promenade may increase in the future.

Coroner’s Conclusions The coroner has concluded that “in my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take any such action you identify.”

He further concludes “I am therefore concerned that falls from the promenade onto the beach, in areas where there is no barrier, would occur again in similar circumstances, as the current signage and markings provide no warning to an individual asleep on their mobility scooter. If this were to occur (as in this case) in an area where the height of drop from the edge of the promenade to the sand was greater than normally expected, I am concerned this would lead to future loss of life.”

Action Taken

Risk Assessments Carried out new risk assessments as a matter of priority, updating the H&S Risk Assessment for Felixstowe Promenade with reviews carried in November 2023 and February 2024.

Developed New Policies and Practices East Suffolk Council Visitor Safety Management Policy (draft format, February 2024) East Suffolk Council Visitor Safety and Asset Inspection Strategy (draft format, February 2024) East Suffolk Council H&S Risk Assessment for Felixstowe Promenade (draft format, February 2024)

What we propose to do:
• Commission a full disability Access Audit of the promenade and its environs by a Centre for Accessible Environments (CAE) accredited assessor.
• Where required install guardrails (possibly removable) or other physical measures, such as corduroy paving, along full length of promenade edge or at parƟcular higher risk points, such as entrance points/ramps off the road and locaƟons where falls are onto rocks or hard surfaces (all subject to 12 months monitoring of beach levels and full disability Access Audit).
• Monitor beach levels at the entrances/ramps to the promenade off the road for 12 months to inform need for addiƟonal guardrails or seasonal relevelling of sand and shingle.
• Renew exisƟng hazard line markings
• Where required extend hazard line markings along edges not currently marked
• InvesƟgate the effecƟveness and pracƟcality of seasonal (or more frequent relevelling of sand and shingle).
• Publicity campaign with other stakeholders to highlight promenade hazards and promote safety.
• Install signage where there is a risk of fluctuaƟng beach levels.
• Publicity campaign with other stakeholders to highlight promenade hazards and promote safety.
• ConƟnue to monitor the structural integrity of the exisƟng barriers and to maintain them.
• We propose to request an up-to-date Safety Audit from Suffolk County Council Highways in relaƟon to highway aspects of the promenade and the road next to it. This will include vehicle and pedestrian movements, signage, cycling, line markings, speed limits, road barriers, kerbs etc.

In addition, we note “evidence was also heard from a mobility scooter supplier and engineer, who explained that falling asleep on a mobility scooter was not uncommon, and happened more frequently than the general public might think. The supplier explained that this often led to accidents, leading to damage to the mobility scooters, which required repair.”

We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.