Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0095, written 4 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2014 |
|---|---|
| Reference | 2014-0095 |
| Deceased | Kathleen Border |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mrs D. Goddard, Manager, Northwood Square 1 | CORONER | am David Clark Horsley, senior coroner, for the coroner area of Portsmouth and South East Hampshire 2 | CORONER’S LEGAL POWERS | 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 9" October 2013 | commenced an investigation into the death of Kathleen Ethel Border. The investigation concluded at the end of the inquest on 7 February 2014. The conclusion of the inquest was: Mrs Border had died due to an Accident. Medical cause of death - Bronchopneumonia as a result of multiple fractures. 4 | CIRCUMSTANCES OF THE DEATH On 13" May 2013, Kathleen Ethel Border, a pedestrian, was struck by a reversing delivery vehicle in Northwood Square, Fareham, sustaining numerous fractures. She was taken to Queen Alexandra Hospital where her condition gradually deteriorated. She died at the hospital at 11.40 hours on 8"" October 2013. 5 | CORONER’S CONCERNS 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. — Mrs Border was struck by a delivery vehicle reversing out of a car parking bay. The vehicle should have parked in a designated delivery area. Signage of the various parking areas in Northwood Square were not very prominent or clear. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 29" April 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to Mrs Border's son, | 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. 47 March 2014 David Clark Horsley Setey
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
@) hanover 04 June 2014 David C Horsley Hanover House Her Majesty’s Coroner for Portsmouth 1 Bridge Close and S E Hampshire Staines Upon Thames Coroner’s Office Middx The Guildhall RECEIVED TW18 4TB 05 JUN 20% BY H.ivi. CORONER Guildhall Square Portsmouth PO1 2AB t 01784 446000 f 01784 446060 — www.hanover.org.uk Dear Mr Horsley Mrs Kathleen Ethel BORDER - Inquest | am writing in response to your letter dated 4 March 2014. | sincerely apologise for the delay in replying. My resident Estate Manager at Northwood Square moved to another position at just about the same time as you wrote to us and | have had a temporary manager covering the estate since that time and so it has taken a little longer to put arrangements in place than it normally would. The delivery vehicle was parked in a short term bay, which is designed for any vehicle which is only going to be parked on site for a short term, i.e. delivering something, collecting a resident or dropping them off for instance. The bays are clearly marked as short term parking bays and pedestrians do not need to walk behind any vehicles parked there as there is a pathway in front of the bays which is accessible to all. Unfortunately sometimes residents and visitors do cut across behind vehicles as a ‘short cut’. Consequently, we have arranged for an extra sign to be fitted making anyone using those spaces aware that there is a danger of pedestrians in the area and to take care when reversing out of the spaces. This sign was fitted on 3 June 2014. We will also be reminding residents and their visitors to take care when walking behind any parked vehicles on the estate through the estate newsletter. | do hope that you will find these arrangements satisfactory and once again | apologise for not keeping you updated Yours sincerely Retirement Housing Manager Phone 02392 838357
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