John Shenton

PFD Report All Responded Ref: 2023-0282
Date of Report 2 August 2023
Coroner John Ellery
Response Deadline ✓ from report 27 September 2023
All 1 response received · Deadline: 27 Sep 2023
Coroner's Concerns (AI summary)
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
View full coroner's concerns
(1) At the inquest you not aware of the report and the recommendations/action required as set out in paragraphs 5.1 to 5.8.

(2) Those actions remain outstanding and should be addressed.

(3) Essentially whilst the descending escalator was fit safe for a non-vulnerable person more should be done to protect a vulnerable person, particularly if they have to use the escalator when the lift is not in operation.
Responses
The Range
1 Aug 2023
Action Taken
The Range has reviewed and updated the escalator and lift risk assessment, and will locate appropriate customer information signage at the lift and escalator in the event of breakdown. They have removed obstructions blocking CCTV coverage of the top of the escalator, and will trial the effectiveness and longevity of high visibility paint to the nosings of the escalator treads during October 2023. (AI summary)
View full response
Dear Mr Re: The late John Neil Shenton deceased Inquest: 1s August 2023 Location: Coroners Court; Shrewsbury Actions taken and to be_taken We write further to the Inquest touching the death of John Neil Shenton which took place on 1 August 2023 and the related Regulation 28 Report dated 2 August 2023_ Firstly, we would like to take this opportunity to again confer our condolences to Mr Shenton's family. We were deeply saddened to learn of his passing Asyou know, an investigation was carried out and a report subsequently produced by Environmental Health Officer, Telford and Reeking Council. The Coroner' $ concerns were directly related to the findings of that report ad, in particular, the recommendations/actions required as set out in paragraphs 5.1 to 5.8_ We think it is important and fair to reiterate the Coroner' $ note made in the Regulation 28 Report which stated that we had not been provided with a copy of report prior to the Inquest and we therefore did not have an opportunity to make appropriate submissions about the report_ Nevertheless, listed below are the actions taken in response to the recommendations made by
1.1 Assess site specific risk posed to vulnerable people and others using the escalator to travel to and from the first floor if the passenger lift is not available. This assessment should extend to customers wanting to move large or heavy items between floors_ Actions; The escalator and lift risk assessment has been reviewed and updated: Appropriate customer information signage will be located at the lift and the escalator in the event of breakdown, advising customers to seek assistance if require assistance t0 move between the floors. Where possible the access route may include the opening of a fire escape staircase provided that there in risk to the customer' $ safety. When opening new stores or ifan existing store is fitted with an escalator, members of staff will be located at the escalators for an initial period to offer guidance and assistance to customers unaccustomed to escalators Risk assessment amended_
1.2 The daily escalator checks and observations should be recorded. Actions: The existing weekly recorded checklist now incorporates the daily informal visual checks. Head Office Switchboard /Business enquiries T:+44 (0) 1752 725572 W: therange co.uk The Range Head Office Elsie Margaret House 15 William Prance Road Plymouth Devon PL6 SZD United Kingdom CDS (Superstores International) Ltd Company Registration No: 2699203 VAT Registration No: 591272335 Search: The Range UK Ellery they

Home R 'Range Gasaee Response to Regulation 28 Report to prevent future deaths
1.3 The illumination readings that are taken by The Range/CDS after an escalator is installed but prior to its use are recorded to demonstrate compliance to BS EN115-1:2017 Actions: CDS have been made aware and the risk assessment amended:
1.4 Staff are trained in how to react if there is a problem with the escalator, including the appropriate use of the emergency button (following the accident on 27/04/2023): Actions: A toolbox talk has created and issued. Risk assessment updated. Non-mandatory recommendations
1.5 Recommendation that checks in place to ensure that the time recorded on CCTV footage is accurate. Action: Store advised to make regular checks and amend time if required
1.6 Recommendation that audible warning be considered to prompt users to embark disembark the escalator_ Action: The reasoning for this recommendation is not known. There does not appear to be any evidence that Mr Shenton was unaware that he was about to step onto the escalator and we would respectfully submit that an audible warning would not have improved the safety of the escalator on the day of the incident: We would also therefore respectfully submit that a lack of audible warning should not give rise to an ongoing concern for the Coroner: It is quite common for escalators to operate without an audible warning system in place. In any event, we are investigating the feasibility and likelihood of improved safety of retro fitment of an audible warning system as a matter of good practice_
1.7 Recommendation that obstructions be removed if they block CCTV coverage of the top of the escalator_ Action: Item removed. Incorporated into risk assessment.
1.8 Recommendation for the addition of high visibility paint to the nosings of the escalator moving treads which could make the edge more visible; this demarcation encourage users to stand correctly on the step: Action: To be trialled the effectiveness and longevity of the paint evaluated: As part of the evaluation the company will consider the level of risk posed by escalators into account the speed and Head Office Switchboard /Business enquiries T:+44 (0) 1752 725572 W: therange co.uk The Range Head Office Elsie Margaret House 15 William Prance Road Plymouth Devon PL6 SZD United Kingdom CDS (Superstores International) Ltd Company Registration No: 2699203 VAT Registration No: 591272335 Search: The Range UK been put could and taking

Home R 'Range Gasden Response to Regulation 28 Report to prevent future deaths gradient of the installation , as well as historical accident data. We anticipate that the trial will during October 2023 We trust that the above information meets the requirements of Regulation 28 but please do not hesitate to contact me if you require any further information. Yourssincerelv Health and Safety Manager (UK and Ireland) Head Office Switchboard /Business enquiries T:+44 (0) 1752 725572 W: therange co.uk The Range Head Office Elsie Margaret House 15 William Prance Road Plymouth Devon PL6 SZD United Kingdom CDS (Superstores International) Ltd Company Registration No: 2699203 VAT Registration No: 591272335 Search: The Range UK
Sent To
  • Range
Response Status
Linked responses 1 of 1
56-Day Deadline 27 Sep 2023
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 the 25th April 2023 I commenced an investigation into the death of John Neil SHENTON. The investigation concluded at the end of the inquest on the 1st of August 2023 with a conclusion of Accidental Death. The medical cause of death was Ia) Bronchopneumonia Ib) Fractured Ribs and II) Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus
Circumstances of the Death
On the 17th April 2023 Mr Shenton, together with his wife and son, went to the The Range, Forge Retail Park, Telford TF3 4PB. Mr Shenton was 82 years of age with limited mobility and was to that extent vulnerable. They initially tried to use the lift in the store but it was not in operation. They went to the first floor by escalator and subsequently Mr Shenton fell stepping on the descending escalator. Mr Shenton sustained injury and sadly as a result died 4 days later at the Princess Royal Hospital, Telford on the 21st April 2023. The circumstances of the accident were investigated and are set out in a report from Telford & Wrekin Council Environmental Health Officer.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.