Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0218, written 8 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2025 |
|---|---|
| Reference | 2025-0218 |
| Deceased | Dorothy Gamby |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Product 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: Prevention of Future Deaths report
Dorothy Gamby (died 30 April 2025)
THIS REPORT IS BEING SENT TO:
Chief Executive Officer
Office for Product Safety and Standards
Cannon House
18 The Priory
Birmingham
B4 6BS
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London E14 0AE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 2 May 2025 an investigation into the death of Dorothy Gamby age
100 years. The investigation concluded at the end of the inquest on 8
May 2025. The medical cause of death was 1a. pneumonia 1b.
fractured neck of femur (operated 22 April 2025). I made a
determination at inquest of accident.
4
CIRCUMSTANCES OF THE DEATH
Dorothy Gamby was 100 years old. On 22 April 2025 she suffered a fall
at home when she stood on the wide claw shaped rubber ferrule that
she had attached to the bottom of her foldable walking stick. This
caused the stick to pull apart and the collapsible mechanism to activate
when she pulled the stick up (the bottom section of the stick being held
down by her foot on the ferrule). When she fell, she sustained fractures
to her right hip and right wrist, and a small subarachnoid haemorrhage.
On 22 April she underwent surgery for her hip fracture. Post-operatively
1
she developed progressive hypoxia and Type 2 respiratory failure,
secondary to known COPD. A chest xray on 25 April showed
pneumonia which was treated with antibiotics. Despite this she
continued to deteriorate, and given her frailty and co-morbidities, her
care switched to palliative care and she died at the Whittington Hospital
on 30 April 2025.
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.
Wide and clawed ferrules for walking sticks are widely available. They
are described as providing stability, support, improved safety, ease of
movement, etc. I am concerned that there is no warning that they may
pose a risk if stood on or trapped when used on folding/collapsible
walking sticks.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 3 July 2025. 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 following.
• Mrs Gamby’s daughter,
• HHJ Alexia Durran, the Chief Coroner of England & Wales
2
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
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.
9
DATE SIGNED BY ASSISTANT CORONER
8 May 2025
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.
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 02. 07. 2025 Melanie Sarah Lee Assistant Coroner Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Dear Ms Lee, Regulation 28: Prevention of Future Deaths Report, Ms Dorothy Gamby Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 30 April 2025, concerning the death of Dorothy Gamby, following a fall Ms Gamby suffered when she stood on a wide claw ferrule attached to a foldable walking stick. I am responding in my role as Chief Executive of the Office for Product Safety and Standards (OPSS). I was very sorry to hear of Ms Gamby’s death. If you have the opportunity, please pass on my sympathies to her family and friends. OPSS is the UK’s product regulator, responsible for the regulation of most consumer products. The regulation of medical devices, which include walking sticks supplied for a medical purpose, is led by the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA has confirmed that walking sticks specifically intended by the manufacturer to provide medical assistance, such as mobility support for elderly or disabled individuals, or are marketed for the compensation of a disability or injury, are classified as medical devices. Such walking sticks fall under the regulatory oversight of the MHRA. As we do not have evidence regarding the specific product in this case, the intended purpose of the walking stick when it was placed on the market is unknown. Where they are not regulated under more specific regulations, consumer products such as ferrules are covered by the General Product Safety Regulations 2005 (GPSR). These require that all consumer products placed on the UK market must be safe. They place responsibility for product safety onto producers, which includes UK businesses manufacturing goods or importing products from overseas. In addition, distributors have a duty of care to not supply products they know, or should know, are unsafe. The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 In determining the safety of a product under GPSR, regard is given to the presentation of the product, including its labelling, warnings and instructions related to the normal and foreseeable conditions of use. To comply with GPSR and be a safe product, the producer must consider the risks posed by their product during foreseeable use and determine whether a warning label, information or other material can sufficiently mitigate those risks. From your report, it appears the hazard occurred when the ferrule was used in combination with a specific style of walking stick capable of folding or collapsing. Where large ferrules are supplied for the specific purpose of being attached to foldable or collapsible medical devices, it is reasonably foreseeable that this hazard may occur, and I would agree with you that warnings should be provided. Unfortunately, I have not received any evidence regarding the specific product that would enable us to determine whether such warnings were present in this case. I would be grateful if you would be able to share further details about the product that was involved in the incident. I have asked my team to work with the MHRA to ensure stakeholders involved in the supply and provision of walking sticks are made aware of this incident and requested to review their risk assessment through contact with British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers alongside medical devices, and any products designed to be attached to them. Thank you again for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Kind regards, Chief Executive OPSS The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss
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