Daniela Pani
28 Mar 2024 · Coroner Robert Simpson · Berkshire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of Samaritan signs on platforms
“A lack of Samaritan signs on the platforms or within the stations”
2. low car park line side fencing
“Car park line side fencing being too low”
3. lack of guidance for service users declining meetings
“training and guidance did not specifically address how to deal with service users declining a visit or meeting”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“(1 During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing.”
This report
“Car park line side fencing being too low. The proposed mitigation was replacement of the fencing.”
Closely relatedConfidence 0.90 · high
Earlier report
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.”
This report
“Car park line side fencing being too low. The proposed mitigation was replacement of the fencing.”