Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0028, written 19 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jan 2024 |
|---|---|
| Reference | 2024-0028 |
| Deceased | John Gray |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer East Suffolk Council Station Road Melton Woodbridge IP12 1RT 1 CORONER I am Nigel PARSLEY, HM Senior Coroner for the coroner area of Suffolk 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 On 20 July 2022 I commenced an investigation into the death of: John Thomas GRAY The investigation concluded at the end of the inquest on 10 January 2024. The conclusion of the inquest was: Accidental Death The medical cause of death was confirmed as: 1a Pneumonia 1b Fractured Ribs, Splenic and Renal Haematoma 1c Trauma II Frailty, Asthma, Obstructive Sleep Apnoea, Stroke 4 CIRCUMSTANCES OF THE DEATH John Gray died at Ipswich Hospital, Heath Road, Ipswich in Suffolk, on the 13th July 2022. John had been admitted to the Ipswich Hospital on the 9th July 2022, after his mobility scooter drove off the promenade at Felixstowe beach, after John had fallen asleep. At the location this occurred, there was no barrier in place to prevent a fall, and the drop was one of several feet. In his fall, John suffered multiple rib fractures leading to respiratory failure. John’s condition continued to deteriorate following his admission, and he passed away at 04:30, on the 13th July 2022. Regulation 28 – After Inquest Document Template Updated 30/07/2021 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Evidence was heard that the height of drop from the edge of the promenade to the sand at the location John fell, whilst on his mobility scooter, was approximately 5 feet. The court was told that, at a number of locations, the height from the edge of the promenade to the sand was prone to change, and a system was in place to monitor this. It was however, acknowledged, that unusual high tide conditions, and/or weather activity could significantly change the drop height in a short period of time. Evidence heard that at high-risk locations, such as areas with persistent long drops, drops onto concrete, or drops onto rock sea defences, permanent barriers were installed. In other areas signage and/or painted markings were used to highlight the risks of a potential fall. It was acknowledged that individuals on mobility scooters were known to regularly access and use the promenade. Due to the demographics of the local area it was acknowledged that the use of mobility scooters on the promenade may increase in the future. Evidence was also heard from a mobility scooter supplier and engineer, who explained that falling asleep on a mobility scooter was not uncommon, and happened more frequently than the general public might think. The supplier explained that this often led to accidents, leading to damage to the mobility scooters, which required repair. I am therefore concerned that falls from the promenade onto the beach, in areas where there is no barrier, would occur again in similar circumstances, as the current signage and markings provide no warning to an individual asleep on their mobility scooter. If this were to occur (as in this case) in an area where the height of drop from the edge of the promenade to the sand was greater than normally expected, I am concerned this would lead to future loss of life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by March 15, 2024. I, the Senior 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: 1. John’s next of kin 2. East Mobility Services (EA) Ltd 3. Motability Operations Limited Regulation 28 – After Inquest Document Template Updated 30/07/2021 4. Howard House Surgery 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 19/01/2024 Nigel PARSLEY HM Senior Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Prevention of Future Deaths Report Executive Summary East Suffolk Council notes the coroner’s findings. In this document, we address the areas of concern and describe steps already taken and considerations for the future. In light of the incident, and prior to the coroner’s conclusion being published, East Suffolk Council reviewed its risk assessments to ensure risks relating to all users, including those with mobility scooters, were considered. The result of those risk assessments forms the basis of the response below. Coroner’s Concerns • Evidence was heard that the height of drop from the edge of the promenade to the sand at the loca�on John fell, whilst on his mobility scooter, was approximately 5 feet. • The court was told that, at a number of loca�ons, the height from the edge of the promenade to the sand was prone to change, and a system was in place to monitor this. It was however, acknowledged, that unusual high �de condi�ons, and/or weather ac�vity could significantly change the drop height in a short period of �me. • Evidence heard that at high-risk loca�ons, such as areas with persistent long drops, drops onto • concrete, or drops onto rock sea defences, permanent barriers were installed. It was acknowledged that individuals on mobility scooters were known to regularly access and use the promenade. Due to the demographics of the local area it was acknowledged that the use of mobility scooters on the promenade may increase in the future. Coroner’s Conclusions The coroner has concluded that “in my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take any such action you identify.” He further concludes “I am therefore concerned that falls from the promenade onto the beach, in areas where there is no barrier, would occur again in similar circumstances, as the current signage and markings provide no warning to an individual asleep on their mobility scooter. If this were to occur (as in this case) in an area where the height of drop from the edge of the promenade to the sand was greater than normally expected, I am concerned this would lead to future loss of life.” Action Taken Risk Assessments Carried out new risk assessments as a matter of priority, updating the H&S Risk Assessment for Felixstowe Promenade with reviews carried in November 2023 and February 2024. Developed New Policies and Practices East Suffolk Council Visitor Safety Management Policy (draft format, February 2024) East Suffolk Council Visitor Safety and Asset Inspection Strategy (draft format, February 2024) East Suffolk Council H&S Risk Assessment for Felixstowe Promenade (draft format, February 2024) What we propose to do: • Commission a full disability Access Audit of the promenade and its environs by a Centre for Accessible Environments (CAE) accredited assessor. • Where required install guardrails (possibly removable) or other physical measures, such as corduroy paving, along full length of promenade edge or at par�cular higher risk points, such as entrance points/ramps off the road and loca�ons where falls are onto rocks or hard surfaces (all subject to 12 months monitoring of beach levels and full disability Access Audit). • Monitor beach levels at the entrances/ramps to the promenade off the road for 12 months to inform need for addi�onal guardrails or seasonal relevelling of sand and shingle. • Renew exis�ng hazard line markings • Where required extend hazard line markings along edges not currently marked • Inves�gate the effec�veness and prac�cality of seasonal (or more frequent relevelling of sand and shingle). Install signage where there is a risk of fluctua�ng beach levels. • Publicity campaign with other stakeholders to highlight promenade hazards and promote safety. • • Publicity campaign with other stakeholders to highlight promenade hazards and promote safety. • Con�nue to monitor the structural integrity of the exis�ng barriers and to maintain them. • We propose to request an up-to-date Safety Audit from Suffolk County Council Highways in rela�on to highway aspects of the promenade and the road next to it. This will include vehicle and pedestrian movements, signage, cycling, line markings, speed limits, road barriers, kerbs etc. In addition, we note “evidence was also heard from a mobility scooter supplier and engineer, who explained that falling asleep on a mobility scooter was not uncommon, and happened more frequently than the general public might think. The supplier explained that this often led to accidents, leading to damage to the mobility scooters, which required repair.” We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.
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