Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0169, written 31 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 May 2018 |
|---|---|
| Reference | 2018-0169 |
| Deceased | Elaine Horrocks |
| Coroner | John Pollard |
| Coroner area | Manchester (West) |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Joseph Holt Ltd., The Brewery, Empire Street, Manchester M3 1JD 1 CORONER I am John Stanley Pollard, Assistant Coroner for the Coroner Area of Manchester West. 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 the 19th January 2018, I commenced an Investigation into the death of Elaine Horrocks, aged 54 years, born 11th October 1963. The Investigation concluded at the end of the Inquest on the 30th May 2018. The medical cause of death was:- Ia Bronchopneumonia and Pulmonary Oedema. Ib Blunt Force Head Injuries The Conclusion of the Inquest was Accidental Death. 4 CIRCUMSTANCES OF THE DEATH She fell down the cellar steps at the Rose Hill Tavern, Westhoughton, when the door was left ajar. The system for getting to and from the cellar was agreed to be unsafe by the Landlady and by the Environmental Health Officer. 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:- (1) (2) There is an unsafe method of work in going to and from the cellar. The cellar steps are insufficiently guarded against accidental entry by the public. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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 26th July 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. 2. Environmental Health Office, Mayor Street, Bolton. 3. (husband), , Licensee, The Rose Hill Tavern, Westhoughton 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 Dated Signed 31st May 2018 John S Pollard HM Assistant Coroner Manchester West 2
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