Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0035, written 24 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jan 2014 |
|---|---|
| Reference | 2014-0035 |
| Deceased | Elizabeth Turnbull |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
3.
CORONER
1
HM Principle Specialist Inspector (Mechanical Engineering)
Chairman, British Industrial Truck Association MHE/7
I am Nicola Jane Mundy, Senior Coroner, for the coroner area of South Yorkshire (East)
District.
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 21st June 2013 I commenced an investigation into the death of Elizabeth Joy
Turnbull, age 65. The investigation concluded at the end of the inquest on 20th January
2014. The medical cause of death was 1a Hypoxic Brain Injury (clinical), 1b Cervical
spine injury with tetraplegia and multiple chest fractures, 1c Mechanical crush trauma.
The short form conclusion of the Jury was accidental death.
4
CIRCUMSTANCES OF THE DEATH
On the 8th June 2013 Elizabeth Joy Turnbull was helping her husband repair a stock
fence when the bucket attached to the end of a telehandler being used to drive the fence
posts in dislodged from the clevices and fell onto Mrs Turnbull. She died on the 15th
June 2013 due to injuries sustained as a result of crush trauma.
CORONER’S CONCERNS
5
During the course of the inquest the evidence revealed matters 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 MATTERS OF CONCERN are as follows. –
(1) The layout of the thumbwheel controls namely one immediately above the other, the
first controlling release of locking pins which secure buckets and attachments, and
the second thumbwheel used to move the telescopic arm backwards and forwards.
(2) The absence of any dual controls which would both have to be activated before the
pins could be released.
(3) Due to 1 and 2 above the ease at which the user could inadvertently release locking
pins rather than moving the telescopic arm
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
1
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 21st March 2014. 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.
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
24th January 2014 Ms N J Mundy
2
See every Prevention of Future Deaths report matching Nicola Mundy, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.