Richard Hedges
PFD Report
All Responded
Ref: 2023-0546
All 1 response received
· Deadline: 13 Feb 2024
Coroner's Concerns (AI summary)
An external concrete staircase presented worn, un-highlighted steps lacking non-slip surfaces, an inadequately short handrail, and poor lighting, increasing the risk of falls.
View full coroner's concerns
(1)The short external staircase where Mr Hedges fell is constructed of concrete steps which are showing signs of wear/weathering. The steps are not coated with a non slip surface and the edges of the steps do not have highlighting to increase awareness. (2)The handrail for use with the steps appears too short at each end and reduces the available support to users of the steps (3) The current lighting of the area of the external staircase is poor.
Responses
Action Taken
The council removed steps and a platform at a bin store to improve safety and accessibility, installed lighting, and removed a similar structure at another location. They believe these actions address all concerns raised. (AI summary)
The council removed steps and a platform at a bin store to improve safety and accessibility, installed lighting, and removed a similar structure at another location. They believe these actions address all concerns raised. (AI summary)
View full response
Dear Sir
Re: Regulation 28 Report to Prevent Future Deaths – Richard Hedges deceased Response of Gravesham Borough Council
I am writing in response to the above Regulation 28 report, to provide details of works undertaken to address your concerns following the conclusion of the inquest into the sad death of Mr Hedges. An action plan was drawn-up immediately following the inquest to determine what works should be carried out to address your concerns and the timescale for these works to be undertaken. A copy of the Action Plan is attached for your information. The decision was taken to remove the steps and platform completely and bringing the walkway back to ground level thereby removing the hazard posed by the steps and also improving access to the bins for wheelchair users.
The types of bins in the storage area will be changing in the near future as there is a requirement to increase recycling within blocks of flats in order to meet the government guidelines. Lighting has been installed within the canopy of the bin store in the form of an LED strip light with sensors so it is triggered as residents enter the bin store. There are also 2 small flood lights with PIR sensors on the car park end of the bin store – these can be seen in the photo below.
During the inquest my officer mentioned that there was another similar structure on the same estate which only had access from steps at one end. These steps have also been removed along with the platform bringing access back down to ground level. The final tarmac floor finish in this area is due to be completed over the next few days. Gravesham Borough Council believes the works undertaken address all the concerns raised in the Regulation 28 report. If you require any further information or clarification, please do not hesitate to contact me.
Re: Regulation 28 Report to Prevent Future Deaths – Richard Hedges deceased Response of Gravesham Borough Council
I am writing in response to the above Regulation 28 report, to provide details of works undertaken to address your concerns following the conclusion of the inquest into the sad death of Mr Hedges. An action plan was drawn-up immediately following the inquest to determine what works should be carried out to address your concerns and the timescale for these works to be undertaken. A copy of the Action Plan is attached for your information. The decision was taken to remove the steps and platform completely and bringing the walkway back to ground level thereby removing the hazard posed by the steps and also improving access to the bins for wheelchair users.
The types of bins in the storage area will be changing in the near future as there is a requirement to increase recycling within blocks of flats in order to meet the government guidelines. Lighting has been installed within the canopy of the bin store in the form of an LED strip light with sensors so it is triggered as residents enter the bin store. There are also 2 small flood lights with PIR sensors on the car park end of the bin store – these can be seen in the photo below.
During the inquest my officer mentioned that there was another similar structure on the same estate which only had access from steps at one end. These steps have also been removed along with the platform bringing access back down to ground level. The final tarmac floor finish in this area is due to be completed over the next few days. Gravesham Borough Council believes the works undertaken address all the concerns raised in the Regulation 28 report. If you require any further information or clarification, please do not hesitate to contact me.
Sent To
- Gravesham Borough Council
Response Status
Linked responses
1 of 1
56-Day Deadline
13 Feb 2024
All responses received
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 6 October 2023 I commenced an investigation into the death of Richard HEDGES. The investigation concluded at the end of the inquest . The conclusion of the inquest was Accident 1a Hypoxic Brain Injury 1b Out of Hospital Cardiac Arrest 1c Fall with Traumatic Cervical Spine Fracture II Chronic Obstructive Pulmonary Disease, Previous Pulmonary Embolism
Circumstances of the Death
Mr Hedges was admitted to the critical care unit following an unwitnessed fall at his residence.
He fell in some short stairs leading to a bin, and was found at the bottom of the stairs with his head down, already looking hypoxic was unresponsive, and a pulse was not detectable. Immediate cardio-pulmonary resuscitation (CPR) was started by a grand-daughter. London Ambulance service arrived and confirmed PEA arrest; further 22 minutes of CPR to obtain ROSC. An iGel was inserted for ventilation. Initially Mr Hedges was very unstable, requiring Adrenaline infusion to maintain blood pressure. On arrival to A&E Mr Hedges was intubated and ventilated. Trauma CT scan revealed an unstable C6 and C7 fracture and bilateral rib fractures (no flail segment).The spine was immobilized and the fracture managed conservatively. The initial CT head showed no signs of intracranial injury except for a superficial haematoma on the scalp. A superficial laceration was sutured in A&E. Mr Hedges was admitted to critical care and stabilised. He was neuro-protected for 48 hours, with full sedation. Initial haemodynamic instability resolved, and he was almost off Noradrenaline. Sedation (Propofol and Fentanyl) was stopped on 24/09 in the morning, but Mr Hedges remained with a GCS E1VtM1, and absent reflexes on triggering of the ventilator. A repeat head CT head was done at 72 hours of admission; this revealed widespread hypoxic brain damage with bilateral uncal herniation, crowding of the foramen magnum, and bilateral extensive infarcts. The overall outcome looked very poor given the prolonged out of hospital cardiac arrest, extensive hypoxic brain injury with uncal herniation and no improvement in neurology. A decision was made to move to comfort care and extubate Mr Hedges, after discussions with the family members. The family mentioned multiple times that Mr Hedges had been deteriorating over the last 6 months prior to admission. He was having memory problems, and had some panic attacks (long-standing problems). Mr Hedges sadly passed away on 26/09/23 @ 15:48
He fell in some short stairs leading to a bin, and was found at the bottom of the stairs with his head down, already looking hypoxic was unresponsive, and a pulse was not detectable. Immediate cardio-pulmonary resuscitation (CPR) was started by a grand-daughter. London Ambulance service arrived and confirmed PEA arrest; further 22 minutes of CPR to obtain ROSC. An iGel was inserted for ventilation. Initially Mr Hedges was very unstable, requiring Adrenaline infusion to maintain blood pressure. On arrival to A&E Mr Hedges was intubated and ventilated. Trauma CT scan revealed an unstable C6 and C7 fracture and bilateral rib fractures (no flail segment).The spine was immobilized and the fracture managed conservatively. The initial CT head showed no signs of intracranial injury except for a superficial haematoma on the scalp. A superficial laceration was sutured in A&E. Mr Hedges was admitted to critical care and stabilised. He was neuro-protected for 48 hours, with full sedation. Initial haemodynamic instability resolved, and he was almost off Noradrenaline. Sedation (Propofol and Fentanyl) was stopped on 24/09 in the morning, but Mr Hedges remained with a GCS E1VtM1, and absent reflexes on triggering of the ventilator. A repeat head CT head was done at 72 hours of admission; this revealed widespread hypoxic brain damage with bilateral uncal herniation, crowding of the foramen magnum, and bilateral extensive infarcts. The overall outcome looked very poor given the prolonged out of hospital cardiac arrest, extensive hypoxic brain injury with uncal herniation and no improvement in neurology. A decision was made to move to comfort care and extubate Mr Hedges, after discussions with the family members. The family mentioned multiple times that Mr Hedges had been deteriorating over the last 6 months prior to admission. He was having memory problems, and had some panic attacks (long-standing problems). Mr Hedges sadly passed away on 26/09/23 @ 15:48
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.