Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0132, written 6 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2026 |
|---|---|
| Reference | 2026-0132 |
| Deceased | Kay Wilson |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| 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) AFTER INQUEST REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Executive – Durham County Council 1 CORONER I am Mr Jeremy Chipperfield, Senior Coroner for the coroner area of County Durham and Darlington. 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 7th January 2026, I commenced an investigation into the death of Kay Wilson, aged 78 years. The investigation concluded at the end of the inquest on 6th March 2026. The conclusion of the inquest was Accidental Death (by drowning). 4 CIRCUMSTANCES OF THE DEATH The deceased drowned shortly after 23:30 hrs on 6 December 2025 when, having been in a public area above the east bank of the River Tees near "County Bridge” in Barnard Castle, she accidentally passed through a gap in a protective stone wall and fell about 9 metres onto rocks and then passed into the river. The river, heightened by recent rainfall, swept her away. 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: A breach in the stone wall running north above the riverside from the east side of “County Bridge", Barnard Castle, provides unrestricted and unguarded access from a public area to a vertical drop of approximately 9 metres onto rocks and the River Tees below. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 1st May 2026. 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 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 Dated: 6th March 2026 Mr Jeremy Chipperfield Senior Coroner for Durham and Darlington
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.
Mr Jeremy Chipperfield Senior Coroner for Durham and Darlington Civic Centre North Terrace Crook DL15 9ES Dear Mr Chipperfield Further to your Regulation 28 report dated 6 March 2026, issued following the inquest into the tragic death of Kay Wilson, I write on behalf of Durham County Council to acknowledge the matters of concern raised and to set out the action taken and proposed. 21 April 2026 Action taken Officers from the council’s health and safety team attended the location on 25 March 2026 to inspect the breach in the stone wall located to the east of County Bridge, Barnard Castle. A site-specific risk assessment for the site had been previously undertaken by council officers for this area and this followed national guidance and methodology. This previous assessment was reviewed and updated to reflect the findings from the inquest. During the same visit, officers also inspected a separate section of wall previously identified as damaged and referenced in associated documentation as part of the Regulation 28 report. This wall was identified as being on the B6277 road on the western side of the river. It can be confirmed that this section had now been fully repaired. See photographs of repair attached in Appendix 1. Resources Durham County Council, PO BOX 274, Stanley, County Durham, DH8 1HG Main Telephone Text Messaging Service www.durham.gov.uk Page 2 of 2 Action planned In relation to the breach in the stone wall running north above the riverside from the east side of “County Bridge" it has been agreed that the most appropriate permanent control measure is the installation of a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below. Advice was sought from the council’s conservation team, who have confirmed their agreement to this proposal, subject to the fencing being installed to the same height as the existing stone wall to maintain the character of the area. Periodic inspections and reviews of the area and the previous risk assessment will continue to be undertaken by council officers and documented. Timescales and assurance An order has been placed for the fencing, and installation is scheduled to be completed no later than Friday 29 May 2026. The council considers that the actions taken and planned directly address the concern identified in the Regulation 28 report and will prevent unrestricted public access to a hazardous drop at this location, thereby reducing the risk of future incidents. Please do not hesitate to contact me should you require any further information or clarification. Yours sincerely Interim Head of Corporate Buildings Durham County Council
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