Sandra Senior: Prevention of future deaths report
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Date of report: 04/03/2024
Ref: 2024-0124
Deceased name: Sandra Senior
Coroner name: Ian Potter
Coroner Area: Inner North London
Category: Suicide (from 2015)
This report is being sent to: Camden Council
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Chief Executive, London Borough of Camden Council, 5 Pancras Square, London, N1C 4AG | |
| 1 | CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 6 October 2023, an investigation was commenced into the death of Sandra Elizabeth SENIOR, then aged 58 years. The investigation concluded at the end of an inquest, heard by me, on 28 February 2024. The conclusion of the inquest was suicide, the medical cause of death being: 1a multiple traumatic injuries |
| 4 | CIRCUMSTANCES OF THE DEATH On 24 September 2023, Sandra Senior travelled to central London. While there she gained access to Tavistock Chambers, Bloomsbury, WC1A; a building comprising of commercial units on the ground floor, with four floors of residential accommodation above. [REDACTED] completed suicide [REDACTED] |
| 5 | CORONER’S CONCERNS During the course of the investigation and inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) The London Borough of Camden Council is the Freeholder of Tavistock Chambers. I learned in evidence from local witnesses and officers from the Metropolitan Police Service that Miss Senior’s death, as a result of using [REDACTED] to complete suicide, was the second of its type within approximately 18-months. The evidence from a resident of one of the flats in Tavistock Chambers set out that the only access to the residential part of the building is through a door[REDACTED], which has “a secure key fob entry system”. However, the evidence was that “We have constant issues with this front entrance either not locking or not opening with the key, there is also a latch to hook the door open at times”. The witness confirmed that the front entrance was hooked open at the material time; this was confirmed by photographic evidence provided by the Metropolitan Police Service. There was also evidence that approximately a year prior to the events of 24 September 2023, “Camden Council locked the only access “[REDACTED].” The witness had assumed that it remained bolted and locked. However, other evidence, including photographic evidence from the Metropolitan Police Service, showed that although there was a clear ‘no entry’ sign [REDACTED], it was not locked shut. A statement from a Detective Sergeant revealed, “A yellow padlock was locked onto the sliding bolt, to give an illusion it was locked, however the clasp had not been held down into the lock, so it could have been opened by any person.” It was also established in evidence that Miss Senior did know any of the residents of Tavistock Chambers or in the vicinity generally. As such, it appeared that her entry to the building [REDACTED] was entirely opportunistic. However, that aside, the evidence suggested that both of the safety systems installed to prevent unauthorised access to the building [REDACTED] were not working effectively at that time. The concern is that it appears that the safety systems in place to stop unauthorised access [REDACTED] in particular, were not operating/being used effectively at the material time and the evidence suggests that this may have been commonplace. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 29 April 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Persons: Miss Senior’s family members [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | Ian Potter HM Assistant Coroner, Inner North London 4 March 2024 |