Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0296, written 13 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Sep 2019 |
|---|---|
| Reference | 2019-0296 |
| Deceased | Lucia Stear |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Robert Jenrick MP Secretary of State Ministry of Housing, Communities & Local Government 2 Marsham Street London SW1P 4DF & Local Government Association 18 Smith Square Westminster London SW1P 3HZ info@local.gov.uk 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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 had been driving her car outside Arrowe Park on the This report is about an infant baby girl, Lucia Jayne Stear who died at 15 hours old. Lucia’s mother, 10.11.2016 at approximately 7.45 when a bough (large branch) from a large Horse Chestnut tree in Arrowe Park, fell on her moving vehicle and broke the windscreen; landing on her abdomen. Mrs Stear had to be extricated from the vehicle and paramedics attended. There was communication with the University Hospital Aintree (the regional major trauma centre) and information was exchanged, including information concerning was taken to Aintree Hospital. Baby Lucia was delivered by emergency C -section at 10:01 hours. She was stabilised at Aintree Hospital and was transferred to the Liverpool Women’s Hospital for ongoing care. Her blood tests showed evidence of multi organ failure. The decision was made to withdraw her treatment and she sadly passed away on 11th November 2016 at 01:11. She died from pregnancy. 1a Multi Organ Failure 1b Antepartum Asphyxia 1c Abdominal trauma with right broad ligament haematoma, sustained in road traffic accident (Maternal condition) During the course of five days of evidence the court heard that following restructuring and staff reductions in the last decade. The regular inspection, condition survey and tree maintenance work on parks and countryside trees in the Wirral was affected. The Court recognised that in spite of austerity statutory services still functioned, however some statutory duties suffered. Expert evidence was given that there needs to be a strategic management of tree policy, with a written policy system to ensure all trees are checked. There also needs to be effective staff training. The purpose of the policy is to detect trees before they fail, so as to keep the public safe, having regard to the location and occupancy of each tree. 4 CIRCUMSTANCES OF THE DEATH (Jury Findings) On 10th November 2016, at approximately 07:45, Elizabeth Stear, who was 36 weeks pregnant, was driving along Arrowe Park Road, when a large bough of a Horse Chestnut tree within the boundary of Arrowe Park, adjacent to the highway, fell onto her white Audi A4, piercing the windscreen, and through the driver's window. The bough impacted her pregnant abdomen, and trapped her inside the vehicle. At 07:57 a 999 call was made and fire, police and ambulance emergency services were dispatched. At 08:10, the rapid response vehicle arrived and indicated that she had not felt her baby move since the incident. At 08:33 left the scene in an ambulance and was conveyed to the Major Trauma Centre at Aintree Hospital, having been categorized as a major trauma, using the North West Ambulance Service (NWAS) paramedic pathfinder major trauma in adults guidelines. At 09:01, was attended by the major trauma team. At 09:07 a midwife could not locate Lucia's heart rate. At 09:10 a fast-scan was performed, which showed that Lucia's heart was beating slowly at approximately 60 beats per minute. At 09:19 it was decided to take for an emergency laparotomy and caesarian section. She arrived in theatre at 09:30 and at 10:01 Lucia was born, with no signs of life. Lucia was resuscitated by teams from Aintree Hospital and Liverpool Women's Hospital and then NWAS transferred Lucia to Liverpool Women's Hospital arriving at 12:40. Tests showed that Lucia had multi organ failure and was extubated and died at 01:11 on 11th November 2016. arrived at Aintree Hospital an JURY CONCLUSION Lucia died as the result of an accident to which the following contributed: a) Wirral Borough Council (WBC) did not have a proactive, robust tree management system in place for Parks and Countryside up to November 2016. They relied upon external contractors to deal with issues on a reactive basis, without having a detailed managerial overview. b) The classification of trees into 'Highways' and 'Parks and Countryside' trees, by WBC failed to identify and manage the risk of all trees within falling distance of the highway. There was a complete failure to have a policy in place for tree management in Parks and Countryside, and a complete lack of risk management for trees at risk of falling onto highways. There had been no formal inspection of trees in Arrowe Park for 13 years previously. c) Inadequate steps were taken to investigate the failed Beech Tree that fell into Arrowe Park Road in January 2015, and rectify mistakes that had been made, including failing to recruit and employ specialist staff for tree management. Had this incident been appropriately investigated, remedial work to the trees along the boundary of Arrowe Park Road would have been carried out. There were missed opportunities to prevent further serious incidents, despite staff concerns and a near- miss event taking place. d) The Horse Chestnut tree had been affected by Bleeding Canker and disease would have been evident on this tree for at least 4 years. e) There was inadequate training of Parks and Countryside staff with regard to tree management and identifying tree hazards, There was no programme of mandatory, ongoing training and there was no Arboricultural officer employed by WBC since 2003. f) There was a systemic lack of accountability and poor communication within and between departments in WBC. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) Before the inquest Wirral MBC put in place a “Tree Action Plan”i which is address the concerns that had been before the court – This is included as an example of what can be achieved when this problem was highlighted by the death of a 15 hour old resident of the Borough. How many other public authorities are in a similar plight, not having had a fatal tragic event to prompt action? The Court asks the Rt. Hon. Secretary of State to address this issue nationally and that he advises the Court as to what steps he has directed to be taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death. The Court requests that the LGA brings this matter to the attention of its Local Authority members and that the LGA advises the court as to what steps the organisation has taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death 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 08 November 2019. 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: Lucia’s family North West Ambulance Service University of Aintree Major Trauma Centre Liverpool Women’s Hospital Wirral Metropolitan Borough Council The Health And Safety Executive and to the Local Safeguarding Board (where the deceased was 18). I have also sent it to who may find it useful or of interest. , Barrell Tree Consultancy – Tree Expert Witness 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 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 13 September 2019
2 responses 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.
Local 48 Government Association Mr Andre Rebello, OBE . : Senior Coroner for Liverpool and Wirral Received Gerard Majella Courthouse Boundary Street 8 10CT 2019 Liverpool L5 2QD H.M. Coroner 30 October 2019 Dear M, Lol dl, Re: Regulation 28 Report into the death of Lucia Jayne Stear Thank you for your Regulation 28 Report following the untimely death of Lucia Jayne Stear. Your recommendation to the Local Government Association required us to bring the matter to the attention of local authority members and advise the court on the steps taken to ensure that there is national learning from this tragic death. An item has been included in my weekly email bulletin to all local authority chief executives. The item will be repeated in the next issue of the LGA’s email bulletin on environmental issues, due in early November. To raise and discuss the findings of your review directly with local authorities the LGA will set up an event with relevant officers by the end of December 2019, using onlineAwebinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members. We will also liaise with the Ministry of Housing, Communities and Local Government to address the recommendations in your report to raise the issue nationally. | hope this gives you a clear picture of the LGA’s response to your recommendation. If you require any further information please let me know. Yours sincerely aod Mark Lloyd , Chief Executive Email: mark.|loyd@local.gov.uk 18 Smith Square, London, SW1P 3HZ www.local.gov.uk Telephone 020 7664 3000 Email info@local.gov.uk Chief Executive: Mark Lloyd Local Government Association company number 11177145 Improvement and Development Agency for Local Government company number 03675577
E Ministry of Housing, Communities & Local Government Andre Rebello Senior Coroner for Liverpool and Wirral HM Coroners Court Gerard Majella Court Boundary Street Liverpool Merseyside L5 2QD Rt Hon Robert Jenrick MP Secretary of State for Housing, Communities and Local Government Ministry of Housing, Communities & Local Government 4" Floor Fry Building 2 Marsham Street London SW1P 4DF Tel: 0303 444 3450 Email: www.gov.uk/mhelg Our Ref: 4484514 Your ref: 03605-2016 <3 | tober 2019 Dear Arndaro, Regulation 28 Report (re. death of Lucia Jayne Stear) Thank you for sending me a copy of your Regulation 28 Report to prevent Future Deaths regarding the death of Lucia Jayne Stear as the result of the branch of a tree in Arrowe Park falling on the moving car in which she was travelling. | am very sorry to hear about this tragic loss of life and would like to take this opportunity to pass on my deepest condolences to her family. You have asked for action to be taken nationally, to stop such an accident happening again. Spending on parks is a matter for local authorities. We acknowledge that local authorities are working under financial pressure, that's why this year the Chancellor has announced the biggest year-on-year real terms increase in spending power for local government in almost a decade. Core Spending Power (CSP) is expected to rise from £46.2 billion to £49.1 billion in 2020-21, an estimated 4.3% real terms increase. This positive announcement brings a significant level of support to local authorities, but we also understand the pressures that they are under in particular areas such as parks and green spaces. In order to provide additional assistance my Department announced in February a total of £9.7 million to be allocated directly to all local authorities across England with the expectation the award be used to undertake remedial work and renovation of existing parks to enhance the green space available to their local communities. This funding enabled local authorities to target funds to those parks in their local area in need of greatest repair and improvement. Wirral Metropolitan Borough Council was allocated a total of £56,295. Thank you once more for sharing your concerns. | would like to reiterate my condolences and | would be grateful if you could convey my sympathy to Lucia’s family. They: a RT HON ROBERT JENRICK MP
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