Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2024-0019, written 5 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Apr 2022 |
|---|---|
| Reference | 2024-0019 |
| Deceased | Sandra Barnett |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| 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.
«AuthorisingUserFullName» «AuthorisingUserAppointment» County of.Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Holme Farm Willow Tree Lane Marsh Chapel Grimsby DN36 SUD .1. CORONER I am Paul Cooper, Assistant Coroner for the Coroner area of Lincolnshire, Myle Cross Centre, 92 Macaulay Drive, St Giles, Lincoln LN2 4EN . . 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. httirtlwww. legislation .gov. u k/ukQga/2009/25/schedu le/5/QaragraQh/7 httQ://www .legislation.gov .uk/uksi/2013/1629/Qart/7 /made 3. INVESTIGATION and INQUEST 1a. Traumatic Subdural Haematoma (Operated) 1b. 1c. 2. 4. CIRCUMSTANCES OF THE DEATH Name of deceased: Mrs Sandra BARNETT Following an unwitnessed fall downstairs whilst on holiday in Grimsby, which occurred at 22:30 hrs on 16/04/2021 at a holiday let hosted by Airbnb (Holme Farm, ). The deceased was admitted to Grimsby A&E before being transferred to Hull for a decompressive craniotomy and subsequently transferred to RBH on 05/05. Underwent further surgery at RPH. Post op transferred to Critical Care. Sedation was removed however patient did not.wake. An EEG initially showed seizure activity. Treated with antiepileptics but her conscious level did not improve. Further imaging CT and MRI scan showed further evidence of haemorrhage in brainstem. A family conference resulted in the decision for EOL care and tre~tment was withdrawn. Patient continued to deteriorate and died. Death verified 21/05/2021 at 1857 hrs. 5. CORONE~SCONCERNS 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 «AuthorisingUserFullName» «AuthorisingUserAppointment» County of Lincolnshire At the time of the fall did the staircase at the holiday home meet regulation standards as to width, depth, handrails and if not, has any remedial work been undertaken since. 6. ACTION SHOULD BE TAKEN In my opinion possible 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 31/05/2022. 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 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. Date: «AuthorisedDateShort» «AAuthhor!s!ngUUserSFignNature» 0 (( ut onsmg ser u11 ame» «AuthorisingUserAppointment» r 2
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.
New Farm 2 GMAY 2021 25th May 2022 Mr Paul Cooper Assistant Coroner Myle Cross Centre 92 Macaulay Drive St Giles LINCOLN LN2 4EN Dear Mr Cooper Regulation 28 Report Mrs Sandra Barnett - Response I am in receipt of your report which relates to a property at Holme Farm, . Please would you note that our names and address for correspondence is as above. The letter was delivered but as the property is not permanently occupied, the mailbox is not checked regularly hence the delay in responding to you. Context: Holme Farm is a detached farmhouse dating back largely to the Victorian period although there is evidence of an earlier farmhouse due to different levels on the ground floor. The property was extensively renovated in 2019/2020. We did in fact do some alterations to the staircase at the top where there was a very narrow tread at the point where it splits into the two accesses to different parts of the house. We enlarged the tread to make it wider and replaced the stair carpet. We discussed replacing the whole staircase with the joiner to make it meet modern standards. However, we were unable to find a solution that retained the historic integrity of the farmhouse without substantial alteration to rooms at both levels. We began letting Holme Farm in October 2020 and the Barnett family were one of the first visitors that we welcomed. We have continued to let Holme Farm without any similar incidents or reports from any visitors of safety issues. Action taken: Following the second visit of the Barnett family in April 2021 and the tragic accident, we immediately took the following steps to prevent future accidents in and around the staircase: 1. A second handrail was added to the wall so that both hands could be used to use the stairs if required. 2. The temporary use of stairgates was ceased and permanent stairgates were fitted at the bottom and at both access points at the top of the stairs. 3. Further information was added to the AirBnb web pages and the Visitors Information pack giving advance notice that this is an old property with steps and stairs and that visitors should be aware and take care if they have mobility issues. I -attach some photographs to illustrate the above. As you can imagine we were deeply shocked at the tragic death of Mrs Barnett especially as we had met her and talked about. the th.ings she had enjoyed during her holiday stay at Holme Farm. Our heartfelt condolences go to her husband and wider family. Yours sincerely,
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