Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0126A, written 9 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Apr 2019 |
|---|---|
| Reference | 2019-0126A |
| Deceased | Freda Mason |
| Coroner | Simon Jones |
| Coroner area | Lancaster & Blackburn with Darwen |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
for Lancashire & Blackburn with Darwen
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Coroner;
– Head of Service
for Public and Integrated Transport, Lancashire County Council [“LCC”] and Antonette
Wilson
1
CORONER
I am Simon Jones, an Assistant Coroner for Lancashire & Blackburn with Darwen
CORONER’S LEGAL POWERS
2
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On I commenced an investigation into the death of Freda Odette Mason aged 67. The
investigation concluded at the end of the inquest on the 9th April 2019. The conclusion of the
inquest was that Freda Mason died an Accidental Death.
4
CIRCUMSTANCES OF THE DEATH
Freda Odette Mason suffered from a number of underlying conditions including chronic obstructive
pulmonary disease and osteoporosis, and had sustained a number of fragility fractures including fractures
to her left humerus and to her vertebrae in 2017. On the 26th July 2018 at approximately 1145hrs, while
sitting at a bus stop at the junction of Burnley Road and Victoria Street Padiham, she fell through the back
of the bus shelter where a panel of glass was missing [and, on the evidence, had been missing for
approximately three months]. She was admitted to Royal Blackburn Hospital at approximately 2325hrs that
same day where she was found to have sustained multiple rib fractures. Surgical intervention and invasive
ventilation could not be provided, due to her underlying conditions, and her respiratory function was
severely compromised. She died in hospital on the 29th July 2018 at approximately 1945hrs.
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. –
LCC has a duty to maintain bus shelters within its area, and does so using a process whereby
complaints are made to LCC by third parties – members of the public, councillors, employees of
LCC and of bus companies – and LCC assesses the complaint and responds , effecting repairs
where necessary. This is best described as a reactive process; and LCC does not operate an
inspection system where it views the bus shelters. This means that unless a third party notifies
LCC of a problem, it has no knowledge of it and cannot respond/repair.
In my opinion a more pro-active system of anticipating necessary repairs could prevent future
deaths; and LCC has the power to take further additional steps to ensure that problems requiring
repair are brought to its attention immediately – whether by implementing a regime of inspection
or by ensuring that those who use/visit the shelters [including bus drivers and inspectors] are
required [or encouraged, where LCC does not have the authority to require it] to notify LCC of
any problem which needs attention.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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
12th June 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 –
.
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 09/04/2019
Signature
for Lancashire & Blackburn with Darwen
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
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.
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS To the Chief Coroner We write in response to the regulation 28 report dated 9th April 2019, from Mr Simon Jones, an Assistant Coroner for Lancashire & Blackburn with Darwin. Mr Jones having investigated the death of Freda Odette Mason, aged 67, concluded on 9th April 2019 that she died an accidental death. The Coroner found that the circumstances of death were as follows:- Freda Mason had suffered from a number of underlying conditions including chronic obstructive pulmonary disease and osteoporosis and had sustained a number of fragility fractured including fractures to her left humerus and to her vertebrae in 2017. On 26th July 2018 at approximately 1145hrs, while sitting at a bus stop at the junction of Burnley Road and Victoria Street Padiham, she fell through the back of the bus shelter where a panel of glass was missing ( and on the evidence had been missing for approximately three months). She was admitted to RBH at approximately 2325hrs where she was found to have sustained multiple rib fractures. Surgical intervention and invasive ventilation could not be provided , due to her underlying conditions, and her respiratory function was severely compromised. She died in hospital on the 29th July 2018 at approximately 1945hrs. The MATTERS OF CONCERN raised by the Coroner were as follows 1. LCC has a duty to maintain bus shelters within its area, an does so using a process whereby complaints are made to LCC by third parties- members of the public, councillors, employees of LCC and bus companies 2. LCC assesses the complaint and responds, effecting repairs where necessary. 3. LCC does not operate an inspection system where it views the bus shelters, therefore unless a third party notifies LCC of a problem, to has no knowledge go to and cannot respond/repair. 4. The Learned Coroner was of the opinion that a more pro-active system of anticipating necessary repairs could prevent future deaths; and LCC has the power to take further additional steps to ensure that problems requiring repair are brought to its attention immediately-whether by implementing a regime of inspection or by ensuring that those who use/visit the shelters (including bus drivers and inspectors) are required (or Encouraged, where LCC does not have the authority to require it) to notify LCC of any problem which needs attention. LCC RESPONSE In Lancashire, there are approximately 2,000 bus shelters situated at bus stops across the county. Approximately one third of these are owned and maintained by the County Council. A further third are directly owned and maintained by district or parish councils with the final third owned and maintained by a number of advertising companies, under contract to either the county or district councils. We are currently in the process of tendering a contract for a service provider to install, maintain, monitor and repair our bus shelter stock as part of a comprehensive overhaul and upgrade programme throughout the county. This contract will allow us to provide a consistent monitoring regime, where every shelter is to be checked every six weeks for any damage, with a structural assessment every twelve months. It is expected that this contract will be in operation from 1st October 2019. In addition to, and prior to the commencement of this contract, we have put in place a number of measures to ensure that any damage to/or issues with any of our bus shelters that require repair, are brought to our attention as soon as practically possible. We have instructed our staff, who may be visiting shelters to update timetable information or for any other reason, to carry out an inspection and to report any damage to a manager with sufficient detail so that a determination can be made as to whether an urgent repair is required. We have written to all bus operators requesting they that they instruct their drivers to also report any shelter damage they observe during the course of their daily duties. We are introducing a more prominently situated 'Report It' notice for members of the public detailing where and how to easily communicate any shelter damage they may find in between the regular checks being undertaken by our own staff or contractors. This 'Report It' process will be managed through the corporate reporting system to ensure the whole process is consistent and information is communicated in the most efficient way. We are responsible for displaying timetable information at bus stops, and the 'Report it' notice will also be displayed on all timetable cases of those bus shelters that are not owned or managed by the county council. This will enable the county council to centrally coordinate any damage reports and ensure the handover of information to the applicable organisation for them to take the appropriate action. We will write to our contacts in district councils and to the shelter owning advertising agencies advising them of our arrangements to mitigate the risk of injury to users of bus shelters following damage and suggest that they may wish to consider their own arrangements and seek their cooperation in ensuring an efficient reporting process. Whilst it's not possible to be aware of shelter damage the moment it occurs, we do expect the measures put in place will bring them to our attention as speedily as reasonably possible and enable any safety critical repairs to be undertaken as a matter of urgency.
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