Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0562, written 5 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 | 5 Aug 2024 |
|---|---|
| Reference | 2024-0562 |
| Deceased | Janet Harrison |
| Coroner | Sunyana Sharma |
| Coroner area | Hampshire, Portsmouth and Southampton |
| 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.
ANNEX A 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. Building Control Inspector, Eastleigh Borough Council 2. Building Control Inspector, Southampton City Council (as building control services are offered in partnership with Eastleigh Borough Council) 1 CORONER I am Sunyana SHARMA, Assistant Coroner, for the coroner area of Hampshire, Southampton and Portsmouth 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 6 September 2022 I commenced an investigation into the death of Janet Karen HARRISON aged 76. The investigation concluded at the end of the inquest on1 July 2024. Janet Karen HARRISON died on 31 August 2022 in hospital from pneumonia following the collapse of her neighbour’s wall on 18 February 2022 for which she suffered from polytrauma. The medical cause of death was confirmed as 1a. hospital acquired pneumonia, 1b. infected left gluteal haematoma, frailty, 1c. polytrauma and 2. hypertension, DVT and cholecystitis. The short-form conclusion reached was accident. 4 CIRCUMSTANCES OF THE DEATH On 18 February 2022, the UK was affected by Storm Eunice for which the Met Office had issued two severe weather warnings. In the area where Janet Karen HARRISON lived, the weather was reported to be wet and windy with gusts of around 50 to 60mph. At approximately 12.10pm on 18 February 2022, Janet Karen HARRISON was found in her garden under her neighbour’s collapsed wall by her neighbour. As a result of the accident, she suffered from life threatening and catastrophic injuries including multiple fractures. Two admissions at Southampton General Hospital followed from 18 February 2022 to 31 March 2022 and from 14 April 2022 until her death on 31 August 2022 and a short admission to Romsey Rehabilitation hospital during the intervening period from 31 March 2022 to 14 April 2022 when Janet Karen HARRISON was deemed to be medically optimised. During her first admission in the hospital she acquired deep vein thrombosis and hospital acquired pneumonia for which she was treated. In her second admission to Southampton General Hospital, she suffered from a bacterial infection and a gastrointestinal bleed for which she was treated. She continued to show signs of an infection in June and July 2022 and was treated for cholecystitis. She also suffered from left gluteal haematoma for which she was treated surgically on 8 August 2022 and 27 August 2022 due to ongoing concerns of infection. She died on 31 August 2022 from hospital acquired pneumonia. The Court heard evidence from Hampshire County Council who gave evidence that the wall was unsafe and should never have been built to a height of 1.95 metres given that it was a half brick wall. The impact of the storm was worsened by the fact that a large surface area of fencing panel was attached to the wall which meant that it was susceptible to collapsing as the fencing panel acted as a sail when exposed to the winds from Storm Eunice thereby contributing to the wall coming down. , Head of the Structural team at 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 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. – I heard evidence from Karen HARRISON whose wall collapsed on 18 February 2022, occupier and neighbour of Janet Karen HARRISON and the family of Janet Karen HARRISON who have all confirmed to me in evidence that there are a number of adjoining properties in the area which have walls built with the same unsafe dimensions as the one that collapsed on to Janet Karen HARRISON during Storm Eunice. , the owner of the property adjoining that of Janet , the I am therefore concerned that if there were other storms in the UK of similar force to that of Storm Eunice then there is a risk of further walls in the local area collapsing thereby placing others at risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation 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 30 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 the Family of Janet Karen HARRISON. I have also sent it to who may find it useful or of interest. 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 5 August 2024 [SIGNED BY CORONER]
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.
In the matter of Janet Karen Harrison (Deceased) RESPONSE OF EASTLEIGH BOROUGH COUNCIL TO THE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1. I am the Head of Legal Services for EBC. In the preparation of this response I have spoken with , the Service Director for Planning and Environment. He in turn has spoken with . 2. EBC delivers its Building Control Service through Southampton City Council, in accordance with a Building Control Partnership Agreement between the authorities. Neil Ferris leads that service; he is the Building Control Partnership Manager (MRICS Dip Mgt MCMI Registered Building Inspector - Specialist). 3. This matter relates to a garden wall to a residential property. Building regulations do not apply to the construction of garden walls, therefore it is not uncommon for a variety of wall types to be constructed by developers when building properties. The legal responsibility for the stability of garden walls rests with the initial contractor when building the property, and then the subsequent property owners. 4. When the local authority receives reports of a dangerous structure, including garden walls, the authority may use powers under s77 Building Act 1984. That involves the authority gaining an order from the Magistrates Court requiring the property owner to carry out works to make the structure safe. This tends to be a matter of last resort, as normally owners respond to informal notifications relating to unsafe structures. 5. In response to this death, , the Principal Building Control Surveyor, conducted a survey of the surrounding garden wall types along Kings Copse Road, using the Land Registry extracts provided to Building Control. The vast majority of these walls appeared to be of robust construction, being one brick thick and with brick and a half piers. 6. Subsequently, the engineer at Hampshire County Council, who gave evidence to the inquest, was contacted. He confirmed the wall which had collapsed was a half brick wall which was 1.9m in height, with one brick thick piers at 3 metre centres. He said the situation was further exacerbated by a timber fence having been attached to the wall, effectively acting like a sail. In his opinion no garden wall of this height and design could be inherently stable when subjected to strong winds. 7. Following this conversation, a wider survey of the surrounding area was undertaken. It is apparent that a large number of houses on Cranbourne Park estate have perimeter garden walls built of a similar design to the one which collapsed, that is being 1.8 to 1.9 metres high, half brick thick and with one brick thick piers at varying centres. 8. These walls are in the region of 40-50 years old. While most of the walls were not showing signs of distress or excessive lean, there was one example of a rear garden wall which had collapsed, possibly as a result of the latest storm. 9. will be undertaking a letter drop to those houses on the estate which have significant length walls of this design, making them aware of the tragic event, outlining the potential stability issues with this type of wall and advising them to seek advice from an experienced builder or engineer to increase the stability of their wall. The letters will be sent within 21 days of today. 10. As no walls currently show immediate risk and therefore do not require immediate remedial action, EBC proposes to revisit the site in 6 months to determine if that remains the case. Should any wall at that point demonstrate potential instability EBC will follow their usual process set out in paragraph 4 of informal engagement with the property owner, and legal action if that does not result in remedial action. 11. We trust this response is satisfactory. Should any further information be required, the coroner’s officer should not hesitate to contact me directly. Head of Legal Services 18th December 2024
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