Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0419, written 20 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Nov 2017 |
|---|---|
| Reference | 2017-0419 |
| Deceased | Terence Davies |
| Coroner | Terence Moore |
| Coroner area | Avon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BANES Parks & Services 2. BANES Highways 3. Canal Trust, Bath 1 | CORONER | am Terence Moore, Assistant Coroner, for the area of Avon 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 10" July 2017 an investigation was commenced into the death of Terence DAVIES, Aged 81. The investigation concluded at the end of the inquest on 20" November 2017 The medical cause of death was la Intracranial bleed Ib Fall Il Anticoagulation for atrial fibrillation The conclusion of the inquest was Accidental death. 4 | CIRCUMSTANCES OF THE DEATH Mr. Davies deceased fell from his mobility scooter whilst travelling along a canal path. He suffered a head injury and later sadly died in hospital. 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 MATTER OF CONCERN are as follows. — The dangerous “informal” pathway seen in attached photo and plan is extant. It is used by pedestrians and cyclists alike who may be in danger by using it to access or egress the tow path 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 16" January 2018. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — the family. . 1am 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 resonse@by the Chief Coroner. 20/11/17 T. G. Moore
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, 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.