Stephen Page: Prevention of future deaths report
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Date of report: 18/12/2025
Ref: 2026-0046
Deceased name: Stephen Page
Coroner name: Ian Potter
Coroner Area: Kent and Medway
Category: Suicide (from 2015)
This report is being sent to: MAPP | Hempstead Valley Shopping Centre
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: (1) Chief Executive Officer, MAPP, 180 Great Portland Street, London, W1W 5QZ [REDACTED] (2) Chief Executive, Hempstead Valley Shopping Centre, Gillingham, Kent, ME7 3PD [REDACTED] | |
| 1 | CORONER I am Mr. Ian Potter, Area Coroner for Kent and Medway. |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 19 August 2025 I commenced an investigation into the death of Stephen Paul PAGE, aged 70 years at the time of his death. The investigation concluded at the end of the inquest heard by me on 17 December 2025. The conclusion of the inquest was: Suicide The medical cause of death was: 1a Ascending Aortic Wall Dissection With Haemothorax And Neck Fracture |
| 4 | CIRCUMSTANCES OF THE DEATH On the morning of 17 August 2025, Stephen Page drove alone to the multi-storey car park of Hempstead Valley Shopping Centre in Gillingham. [REDACTED]. Despite efforts to treat Mr Page, a paramedic verified the fact of his death on scene at 10:42 on 17 August 2025. Mr Page died as a result of the traumatic injuries he sustained. He had intended his actions to bring about his death. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – (1) Written evidence from a senior member of staff at MAPP (who provide security management at Hempstead Valley) set out that there is an electronic sensor system in place [REDACTED].The evidence was that, “When the sensor beam is broken, the corresponding CCTV camera automatically moves to the activation point and displays a visual alert marked ‘Alarm’. The camera remains focused on the area to allow for monitoring if an operator is present.” The investigating officer from Kent Police, said in their statement, “This ‘alarm’ is visual only and displays for a few seconds. Due to the number of screens, this could have been easily missed by the CCTV operator.” For the avoidance of doubt, the evidence suggested that the alarm system was working and operational on 17 August 2025. Further, there was no evidence of a delayed response in this particular instance. However, it is not difficult to envisage (particularly given that there is no audible alarm) a situation in which a triggering of the ‘alarm’ could be missed and an opportunity for staff to intervene being lost. |
| 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 by 12 February 2026. 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 to the following Interested Persons: • Mr Page’s family. 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. She may send a copy of this report to any person who she 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 | 18 December 2025 Signature Ian Potter Area Coroner for Kent and Medway |