Prevention of Future Deaths reports · 2017

Roseleen O’Donoghue

Regulation 28 report to prevent future deaths, reference 2017-0007, written 3 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Jan 2017
Reference2017-0007
DeceasedRoseleen O’Donoghue
CoronerChristopher Murray
Coroner areaManchester South
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: The Chief Executive, Your Housing, 602 Aston
Avenue, Birchwood Park, Warrington, WA3 6ZN

CORONER

lam, Christopher Murray Assistant coroner, for the coroner area of South Manchester

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

INVESTIGATION and INQUEST

On 4" July 2016 | commenced an investigation into the death of Roseleen Mary
O'DONOGHUE. The investigation concluded on the 23% November 2016 and the
conclusion was one of Accidental Death. The medical cause of death was 1a) Traumatic
scalp laceration and subdural haemorrhage.

CIRCUMSTANCES OF THE DEATH

Mrs O'Donoghue fell down her stairs at home on the 26" or 27" June 2016 which
resulted in a traumatic fatal head injury sustained in the impact following the fall
and she was pronounced dead at the scene on 27" June 2016.

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 stair lift fitted at 7 Radnor St
does not come to rest in the safest possible position when at the top of its journey giving

rise to a risk of falling, as the step plate is suspended over the stair well. | am concerned
you may have other properties featuring the same type of risk.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 28" February 2017. |, the coroner, may extend the period.

Your response must contain details of action taken of 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 the next of kin, who may find
it useful or of interest.

| 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 i
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.

Mr Christopher Murra’ Ww Assistant Coroner
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