Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0396, written 23 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jul 2024 |
|---|---|
| Reference | 2024-0396 |
| Deceased | Fredrick Dunbavin |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Director Seascape Homes and Property Limited 1 CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset 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 the 14th December 2023, an investigation was commenced into the death of Frederick Barrie Dunbavin, born on the 30th June 1948. The investigation concluded at the end of the Inquest on the 9th July 2024. The Medical Cause of Death was: 1a Multiple Injuries 1b 1c 2 Complete Occlusion of the Left Coronary Artery The conclusion of the Inquest recorded that Frederick Barrie Dunbavin died as a consequence of an accident. 4 CIRCUMSTANCES OF THE DEATH Frederick Barrie Dunbavin, who was diagnosed with dementia and who experienced periods of confusion, fell from a wooded area in the grounds of the Treetop Apartments onto a concrete path that runs to the rear of the St Stephen’s church hall. 1 As a consequence of the fall, Mr Dunbavin sustained multiple injuries, which caused his death. A police investigation revealed there is a low wooden fence separating the wooded area from a parking area at the apartment complex. However, there is a gap in the fence, allowing easy access to the woodland, and no barrier between the wooded area and the drop onto the path that runs to the rear of the church hall. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. There is open access from the carpark area at The Treetops Apartment complex to the wooded area that Mr Dunbavin accessed before he fell. In addition, there is no barrier between the edge of wooded area and the pathway that runs to the rear of the church hall. Finally, there is no signage to warn that there is a dangerous drop from the edge of the wooded area onto the path below. 2. I have concerns with regard to the following: i. Mr Dunbavin sustained multiple injuries following a fall from the wooded area at the Treetops Apartment complex, having accessed the wooded area from the parking area. There was nothing that prevented him from accessing this area, or warning him of the drop from the wooded area. I understand that no changes have been made subsequent to Mr Dunbavin’s death. Therefore, there remains a risk that access can be easily gained to this area, with a risk of life-threatening injuries should anyone fall from the wooded area to the path below. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, by 17th September 2024. 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: (1) 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 Dated 23rd July 2024 Signed Brendan J Allen 3
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.
Private & Confidential 15 October 2024 Dear Coroner RE: 35373940 Inquest on the death of Frederick Barrie Dunbavin Firstly, I would like to apologise for the late response in regards to this matter. The board of directors were awaiting legal advice around the responsibilities of the land in question which the company lease from BCP Council. The company has had a HHSRS assessment carried out. It was the assessor qualified opinion that it would be reasonable to extend the existing metal key clamp barrier along extent of the boundary to further deter access to the neighbouring public land. The Council is installing wire mesh along the bottom section of all metal key clamp barriers on site to further restrict anyone gaining access. In addition to the recommended works, signs advising ‘No Access & fall risk’ have also been installed. With regard the fall risk which is situated further in on the neighbouring public land, BCP Highways manages the site. It will be for the relevant officer in BCP Highways to consider how they are going to address/mitigate the fall risk. Here’s a picture of Seascapes boundary with the neighbouring public land to refresh, it shows the metal key clamp arrangement on the left which is being extended across the full length of the boundary to the right. Yours sincerely Director
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