Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0189, written 9 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2023 |
|---|---|
| Reference | 2023-0189 |
| Deceased | Elsie Murphy |
| Coroner | Nicholas Shaw |
| Coroner area | Cumbria |
| Category | Other 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
19 May 2023
THIS REPORT IS BEING SENT TO: Chief Executive, Cumberland Council, Carlisle
CORONER
I am Dr Nicholas Shaw, HM Assistant Coroner for Cumbria
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 30 September 2022 I commenced an investigation into the death of Elsie Mary
MURPHY, aged 86. The investigation concluded at the end of the inquest . The
conclusion of the inquest was
Death due to an accident
1a Acute on-chronic sub-dural haemorrhage
1b
1c Fall
II Anticoagulated for atrial fibrillation
CIRCUMSTANCES OF THE DEATH
On 27th September 2022 Elsie was walking along the footpath from that leads from
4 Windermere Road to Ewanrigg Road in Maryport to reach a bus stop. immediately below
the steps leading up to Ewanrigg road the path turns 90 degrees right, Elsie slipped in a
puddle that had formed here and fell, sustaining her fatal injury. She died in Cumberland
Infirmary the following day.
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. –
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Evidence was heard that a puddle always forms at this location in wet weather and
that people have slipped here in the past. Pictures taken on the evening Elsie fell were
accepted in evidence and are attached. It seems that a drain or soak away from under
Ewanrigg Road discharges down the grassy bank to the left of the steps looking up them
and pools on the path. There is a drain on the right hand side of the path a few feet from
the base of the steps but water does not seem to reach it. I am concerned that if this issue
is not addressed by some remedial work further accidents will occur
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your council
have the power to take such action.
YOUR RESPONSE
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You are under a duty to respond to this report within 56 days of the date of this report,
7 namely by 14th July 2023. 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Person
, Elsie's daughter.
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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.
19 May 2023
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Signature
Dr Nicholas Shaw HM Assistant Coroner for
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.
"'1# ~ffi,.,,. r-../ Cumberland Council " " ' Cumbria House 117 Botchergate Carlisle Cumbria CA1 1RD cumberland.gov .uk 10 July 2023 Kally Chemma LLB Senior Coroner Cumbria Fairfield, Station Road COCKERMOUTH Cumbria CA13 9PT Dear Ms Cheema THE LATE ELSIE MARY MURPHY-DECEASED INQUEST: 18 MAY 2023 AT CORONER'S COURT-COCKERMOUTH Thank you for your letter dated 23 May 2023 in relation to the above Inquest and the Regulation 28 report dated 19 May 2023 regarding the same. Firstly, on a personal note, can I say how sad I was to hear about Elsie's passing and we send our condolences to her family and close friends. In response to the Regulation 28 report, the Council has made a number of enquiries. Ownership/responsibility for the area of land in question We can now confirm that we have completed our internal enquiries into this matter and have been able to clarify the following in relation to the area of land in question: • The area of land is not under the registered ownership of Cumberland Council. • The area of land is not under the registered ownership of the previous district Council Allerdale Borough. • The area of land is shown on the street gazetteer, held by us as the Transport Authority, but only as a private street with access for pedestrian and vehicle traffic. • Cumbria County Council as Highway Authority had in the past repaired the road lighting at this location. • None of the area in or around the immediate area of the incident is inspected by Cumberland Council as Highway Authority. • Neither the lane/part grassed area between 25 Ewanrigg Road and the hospital leading up to the steps onto Ewanrigg Road nor the path at the location of the incident which turns 90 degrees right at the steps and runs in front of the houses on Ewanrigg Road has any registered owner. • The area of land is not a recorded Public Right of Way (footpath, bridleway etc). Page2 Kally Chemma LLB 10 July 2023 • The steps do not form any structure that is inspected or maintained by Cumberland Council. Taking the above information into account, the Council has now exhausted all available avenues of tracing the owner of this area of land. As Highway Authority, Cumberland Council has a power albeit not a duty under 130 (2) of the Highways Act 1980 to "assert and protect the rights of the public to the use and enjoyment of any highway in their area for which they are not the Highway Authority ... " Remedial action undertaken/proposed With this in mind, the Highways Department had commenced work to install additional drainage in this area to further prevent standing water. Subsequent to that work commencing, information was received from United Utilities and it would appear that their water/sewerage systems may have been defective and contributed to the standing water. United Utilities have confirmed it has now been repaired and is currently being monitored by them. Should the problem reappear, we will take further action as required. Yours sincerely Chief Executive
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