Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0194, written 23 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jun 2022 |
|---|---|
| Reference | 2022-0194 |
| Deceased | Peter Moorby |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
KALLY CHEEMA SENIOR CORONER County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cumbria County Council 1 CORONER I am Miss Kirsty Gomersal Area Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST On 10 September 2021, an investigation was commenced into the death of Mr Peter John MOORBY (“Peter”). Peter’s inquest was opened on 22 September 2021 and concluded on 8 February 2022. The medical cause of Peter’s death was: 1a Head Injuries The determination was: Mr Peter John Moorby died at the Royal Lancaster Infirmary on 5 September 2021. Mr Moorby had been seen to leave a friend's house at about 22:30 on 4 September 2021. At approximately 01:00 on 5 September 2021, Mr Moorby was located in a beck off Millstream Court, Cark-in-Cartmel, with a severe head injury. His entry into the water was unwitnessed. Mr Moorby was found at the bottom of an 8-10 foot drop having fallen over a knee high wall in an unlit area. Mr Moorby was treated at the scene and during transfer to the Royal Lancaster Infirmary. Treatment continued there but Mr Moorby died at 05:50. Post-mortem blood evidence alcohol The conclusion of the inquest was: Accidental Death. 4 CIRCUMSTANCES OF THE DEATH On the evening of 4-5 September 2021, Peter had been visiting a friend’s house on . When he left his friend’s house, Peter was well although under the influence of alcohol. On 5 September 2021 at approximately 01:00, residents of someone in distress. Mr Moorby was found in the beck which is on the opposite side of a low wall that runs alongside the access road to heard . Peter had a severe head injury and was partly in the water. Peter’s entry point into the beck was over the low wall which is less than knee height. Peter had fallen approximately 8 – 10 feet into the beck. Evidence was heard from a number of emergency services personnel about the difficulties in extracting Peter from the location. Peter subsequently died from the injuries sustained in the fall. Evidence was given at the inquest that there is danger during the hours of darkness as the area is unlit, the wall is so low and there are no barriers to prevent anyone falling. 5 CORONER’S CONCERNS 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: I am concerned about the risk of future deaths posed by the low wall. The wall is less than knee height and offers no real protection from the significant drop of 8-10 feet into the River Eea which has a rock-strewn riverbed. The area is also unlit at night. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that you have the power to take such action: . I believe on which the access road and low wall is situated. to be the owner of the freehold of the land AND I understand that maintenance of the access road is shared equally between those properties abutting the access road. As the wall appears to retain the road, I believe that the low wall forms part of the access road. This Notice is therefore served on those properties adjoining the access road: owner of a property adjacent to the access road. . The Land Registry details indicate they are the the access road. Land Registry details indicate he is the owner of land adjacent to property adjacent to the access road. The Land Registry details indicate they are the owner of a owner of a property adjacent to the access road. . The Land Registry details indicate they are the AND Cumbria County Council of Cumbria House, 117 Botchergate, Carlisle, CA1 1RD as Street Works Authority under the Highways Act 1980. This Report has been delayed due to the difficulties in ascertaining who is responsible for the access road / low wall. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 August 2022. 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: , Peter’s mother. 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 23 June 2022 Miss Kirsty J Gomersal HM Area Coroner County of Cumbria
4 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.
Cumbria County Council Economy & Infrastructure Directorate 107-117 Botchergate Carlisle Cumbria CA1 1RD 9 September 2022 Our reference: PG/CR Senior Coroner’s Officer - HM Coroners Service (Cumbria) HM Coroner Fairfield Station Road Cockermouth CA13 9PT Dear Peter John Moorby Ref 2443416- Regulation 28 Report Cumbria County Council (“The Council”) acknowledges receipt of the Regulation 28 report to prevent future deaths in this matter and provides this response as Street Authority under the Highways Act 1980. The Council expresses its sorrow for Peter Moorby’s death and offers its condolences to Mr Moorby’s family and friends. The Council acknowledges its locus as Street Authority in considering action which may be required to prevent future fatalities at Millstream Court, a private unadopted street in Cark-in- Cartmel, South Cumbria. The Council has considered the Regulation 28 report to prevent future deaths and notes that as the wall is on a private street, that primary responsibility for action lies with the owners of the properties fronting the street. The Council has considered the responses of the residents, and notes that has not yet provided a response. The Council notes that the residents do not believe any action is necessary to safeguard pedestrian and vehicular traffic and that they object to any increase in the height of the wall on grounds of amenity. The Council commits to fulfil its duty as a Street Authority under the Highways Act and will work with the residents to support them to take action to reduce the risk and likelihood of future accidents from the wall. Serving the people of Cumbria cumbria.gov.uk The Council aims to meet with residents not later than the end of November 2022 to try to reach agreement on a way forward not later than the end of January 2023. Failing that, the Council will take the appropriate enforcement action, with a view to completion of the necessary works as soon as possible thereafter. Yours sincerely Assistant Director Highways & Transport
From: Sent: Mon Aug 15 18:11:40 BST 2022 To: Subject: Case ref. 2443516 Death of Peter John Moorby. To The Coroner; We are answering your request re prevention of further deaths. 1. We feel this death was a freak accident. 2. We have lived here for 20 years and there have been NO accidents involving the river wall. In fact our neighbours say none have ever occurred in the last 30 years. 3. The part of the wall in question has no embankment, but is a straight fall on to rocks when the river is low. Most of rest of wall up to main road has a grassy or bushy bank. 4. The road is wide. Refuse trucks, removal vans, large delivery vans all use the road .There is no reason for people to walk into the wall. 5. Mr Moorby was seen earlier in the afternoon in question, walking unsteadily with a beer in his hand in the small park opposite the accident site. He was seen shortly after that on Cark Bridge leaning on the bridge wall, unsteady on his feet. 6. It is unfortunate that he was not accompanied or safe travel arranged when he left his friend's house later that evening. 7.The road is a cul de sac. It is NOT a thoroughfare. Residents, their family and delivery people use the road. There are a limited amount of people who use it. 8. Regarding our part of the wall, we have solar lights in summer to light up our short drive and road in front of the house. We have an electric light to use in winter. 9.We moved to our house on our retirement 20 years ago. We chose this house because it is a quiet location. We really enjoy watching the wildlife on the river. Kingfishers, Dippers, Wagtails, Herons, Eels and many ducks give us much pleasure. We would not have moved here if there had been a high wall facing our house. I am 76 and my husband is 81. We hope you find the above information useful , please contact us if you require any further information. Yours faithfully, WARNING:Email attachments may contain malicious and harmful software. If this email is unsolicited and contains an attachment DO NOT open the attachment and advise the ICT Service Desk immediately. Never open an attachment or click on a link within an email if you are not expecting it or it looks suspicious. Do not forward chain emails.
Coroner Fairfield Station Road Cockermouth CA13 9PT Dear Sir 18th August 2022 With ref to your letter of !3'd June 2022. We personally have no issue with the wall. There are low walls all over Cumbria. And in actual fact further down the beck in Cark there is a large area with a drop that has no wall at all. It was very sad when Mr Moorby was found in the beck on 5th September 2021 whatever the circumstances had been. Mr Moorby was extremely inebriated. However we would be willing to contribute to put a sign on the wall stating 'low wall' if ALL the residents did and not just the ones mentioned in your letter. . And would be willing to put up an P.I.R light on our property 11 Millstream Court which would light up the access road in front of our property when someone went passed. We could not guarantee this would work every time and We would have to pay for this.
HM Senior Coroner Fairfield Station Road Cockermouth Cumbria CA13 9PT 24th August 2022 Dear Madam RE: The late Peter John Moorby We are in receipt of your letter of 23rd June 2022 and the Regulation 28 Report to Prevent Future Deaths. I regret the delay in responding, but we have been away on an extended break since May and only returned home yesterday. We note the contents of your report, but would state that we do not consider further action to be necessary for the following reasons: - 1. The incident was a single unfortunate accident, rather than the latest in a series of deaths. The gentleman was highly intoxicated and had been seen in the village and wandering on the road on several occasions during that afternoon and evening in a very inebriated state. We have lived in this village for over thirty years and have never experienced anyone with a problem with the river. 2. One simply cannot fall over the wall and into the river. The route from the house he was leaving to the main road would have led him well away to the right of the wall. He must have deliberately chosen to veer from the natural route and sit on the wall. Most of the stretch between the main road and the spot where he fell has a grassy bank or a bank with undergrowth and shrubs. To raise the level of the wall or indeed to erect any kind of barrier would completely spoil the enjoyment of the wildlife and ambiance of the setting. 3. The wall is adjacent to an unadopted road. This is not a narrow lane (4metres), but a road wide enough to take refuse vans, delivery vans etc. 4. The road is not a public thoroughfare. It is a private road for the use of all the residents of 5. the lower part of Millstream Court. It is a cul de sac. There are several solar lights and motion sensors lights along the unadopted road, so it is not in total darkness. It would be inappropriate and costly to install street lighting and would be harmful to the “Dark Sky ethos” and the local observance of the wildlife. We, and other residents, do not feel any further action is necessary and, whilst we note your recommendations, we feel most strongly we should not have to bear any cost and considerable inconvenience and the diminishment of our enjoyment of our environment through the complete lack of judgement of one drunken individual. Yours faithfully
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