Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0437, written 9 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2014 |
|---|---|
| Reference | 2014-0437 |
| Deceased | Stephen Simpson |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| 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.
Tony Brown LLM
H M Senior Coroner
North Northumberland
Teleph
17 Church Street
Berwick-upon-Tweed
TD15 1EE
Tel : 01289 304318
Fax : 01289 303591
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive
Home Group
2 Gosforth Park Way
Gosforth Business Park
Gosforth
Newcastle-upon-Tyne
NE12 8ET
1
CORONER
I am Tony Brown, senior coroner, for the coroner area of North Northumberland
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 14th March 2014 I commenced an investigation into the death of Stephen Peter
Simpson, a fifty year old man, who died in hospital as a result of a skull fracture after a
fall at home on the 14th March 2014. The investigation concluded at the end of the
inquest on 10th June 2014. The conclusion of the inquest was that Stephen Peter
Simpson died as a result of an accident, the medical cause of death being:-
1a Brain Haemorrhage
1b Skull Fracture
4
CIRCUMSTANCES OF THE DEATH
Mr Simpson appears to have fallen down communal concrete stairs during late evening
on 13th March 2014 and struck his head on the external door immediately at the bottom
of the stairwell. Mr Simpson was showing faint signs of life when found by a neighbour
the next morning and paramedics were called. Sadly he could not be resuscitated and
death was pronounced at Wansbeck General Hospital at 13.50 hours.
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. –
The design of the building is that there is no entrance lobby or passageway to arrest any
accidental fall, with the result that any person who slips or falls while negotiating the
communal stairs is liable to sustain serious injury from making impact with the solid
external door. Additionally, the stairs are constructed of smooth concrete without the
addition of any non-slip surface. Even if a non-slip surface was present, this would not
obviate the risk of serious injury or death from impact with the external door, if a person
falls from the stairs.
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 5th December 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 and to the following Interested
Persons,
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
DATE 09 October 2014
TONY BROWN
HM Senior Coroner for North Northumberland
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