Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0480, written 28 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Aug 2024 |
|---|---|
| Reference | 2024-0480 |
| Deceased | Elizabeth Bury |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire |
| 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Staffordshire Moorlands District Council 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of Staffordshire 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 12 April 2024, I commenced an investigation into the death of Mrs Elizabeth Margaret Bury. The investigation concluded at the end of the inquest on 13 August 2024. The conclusion of the inquest was a narrative conclusion comprising of “complications following a fall.” The cause of death was: 1a Bilateral haemothorax due to rib fractures and cardiac laceration 1b Fall 1c II Ischaemic heart disease 4 CIRCUMSTANCES OF THE DEATH i) Mrs Bury was walking back to her care in Tape Street Carpark in Cheadle on the 15 February 2024. She fell on a speed bump in the car park. This caused bilateral haemothorax due to rib fractures and cardiac laceration. She passed away at the carpark. 5 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. – 1. That this carpark has been the source of many falls because of the speed bumps. 6 ACTION SHOULD BE TAKEN In my opinion 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, 1 [IL1: PROTECT] namely by 16 October 2024. 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. Family of the deceased; 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 28 August 2024 Miss Emma Serrano Area Coroner Staffordshire Area 2 [IL1: PROTECT]
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.
To: Emma Serrano, Area Coroner Stoke-on-Trent & North Staffordshire Coroner Stoke on Trent and North Staffordshire Stoke Town Hall, Kingsway, Stoke-on-Trent, ST4 1HH (sent by email to case Progression Officer ) Tuesday, October 15, 2024 Dear Coroner, Response to Prevention of Future Deaths Report. We acknowledge receipt of the Prevention of Future Deaths report, issued following the inquest into the death of Elizabeth Margaret Bury on 13th August 2024. The Council wishes to express its sadness and concern upon reading the details in the report. Please be reassured that we take these matters very seriously indeed, and we are grateful for the opportunity to set out the action we have taken to prevent future deaths. Overview of the Issue Raised In your report, you have identified that Tape Street Car Park, Cheadle, where the incident occurred, has been the source of many falls because of speed bumps. Actions Taken to Address the Concerns Since receiving your report, we have undertaken the following steps: • The day after receiving your report the Council’s Corporate Health and Safety Manager visited the car park accompanied by a Senior Compliance Officer from the Council’s Assets team. The purpose of the visit was to assess the overall condition of the car park, including the traffic 1 calming measures currently in place. It was noted that the speed bumps were highlighted with white thermoplastic road marking paint which were in good condition and visible. • On the 9th October 2024, a further inspection was undertaken by a representative from the British Car Parking Association, accompanied by a Council Officer and a Police Officer from Staffordshire Police. It was confirmed that the car park meets the ‘Park Mark’ scheme which establishes national safety standards. Notwithstanding the matters found during the site visit, the Council has carefully considered the content of your report and will action improvements to the car park as set out below. Ongoing Commitments The professional advice we have received has resulted in the following planned action: • The Council will remove the speed bumps closest to where we understand the incident to have occurred. Subject to design advice, the current speed bumps will be replaced with a larger speed bump, with a flat top, which will adjoin the pedestrian platforms at either side. The top of the new speed bump will be painted to delineate a zebra crossing, and to provide a flat walking platform of consistent height all the way across between the two platforms. The Council will look to expedite the works and we expect to have them completed by the end of this year. • In the interim period, the Council will investigate whether additional signage can be added to make pedestrians aware of speed bumps/uneven surfaces, and where and how these can be placed on site. We hope the steps outlined above demonstrate our commitment to preventing future deaths and our determination to address the matters identified in your report. Should you require any further information, or if you wish to discuss any part of our response in more detail, please do not hesitate to contact us. Once again, we offer our sincere condolences to the family of Ms Bury and assure you that we are taking all necessary steps to prevent any similar incident from occurring in the future. Yours sincerely, 2 Head of Legal Staffordshire Moorlands District Council 3
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