Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0535, written 23 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2025 |
|---|---|
| Reference | 2025-0535 |
| Deceased | Ann Campbell |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Landlord 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 1/10/25, I concluded the inquest into the death of Ann Campbell. I recorded the cause of death as 1a) Skull fracture II) Alcohol intoxication I recorded a conclusion of Accident 4 CIRCUMSTANCES OF THE DEATH Ann lived in a basement flat at 11 Tolver Place Penzance Cornwall that is reached by using a set of steep, concrete steps. On 15/11/24, she was found deceased at the foot of the steps. At post-mortem, a skull fracture was identified and it is likely this was caused by Ann falling down the steps. It was also noted that she was likely to have been under the influence of alcohol at the time. The steps are narrow and appear poorly lit. There is a handrail on one wall but, for someone about to descend the steps, it is too low to grasp. 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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 Information Classification: CONTROLLED 1) Access to the steps is difficult. In particular, someone who is about to descend the steps is not able to steady themselves by grasping a handrail because it is too low/does not extend up higher than is currently the case. 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 18 December 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 Chief Coroner and to the following Interested Persons: - , brother of deceased. 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 [DATE] [SIGNED BY CORONER] 23/10/25 2
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.
From: rags1947@hotmail.co.uk To: coronersservice@cornwall.gov.uk Sent: Fri Oct 24 2025 10:16:45 BST Subject: Re: Death of Ann Phyllis Campbell - Regulation 28 report ( ) CAUTION: This is an EXTERNAL email which was sent from outside of Cornwall Council's network. Do not click links, open attachments, or reply unless you recognise the sender and know the content is safe. Do not provide any login or password details if requested. Dear Lucie, Thank you for the report regarding Anne Campbell - Deceased. Please advise Mr Andrew Cox of the following: Regarding the hand rail you mentioned, this is due to the wall height, however, I asked the contractor to look at this and it has been suggested by the contractor that a grab rail on the top of the wall would be the best way to sort this problem, this will be fitted ASAP. With regard to the lighting our electrician visited the flat on our behalf 4 weeks ago and work to supply lighting should be completed in the next 3 weeks. I would like to inform the coroner that at the time of purchase no signs were in place to advise steep steps, 2 signs were put in place very soon after the purchase. The steps were also cleaned and a coating of non slip substance which had sand in it used on yacht's was also done for extra safety. The handrail itself is now fully secured along the rail, again done when we took over. Please be assured that safety is a priority for our properties. If you are not in agreement for a grab rail to be fitted, would you kindly advise. Thank you. Yours sincerely, Rosalind Goff Penzance Property Ltd.
See every Prevention of Future Deaths report matching Andrew Cox, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.