Prevention of Future Deaths reports · 2026

Edith Millington

Regulation 28 report to prevent future deaths, reference 2026-0183, written 27 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Mar 2026
Reference2026-0183
DeceasedEdith Millington
CoronerAndrew Bridgman
Coroner areaManchester South
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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. 

Road, Altrincham WA14 3PD   

1 

CORONER 

, Directors SAI SKN Ltd, 13 Gaddum 

I am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South   

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 16.10.25 an inquest was opened into the death of Edith Millington who died at 
Salford Royal Hospital on 09.09.25.   
The inquest concluded on 24.03.26.     

Medical Cause of Death 
1a) Traumatic Intracranial Haemorrhage    

2)   Paroxysmal Atrial Fibrillation  

The conclusion was one of  

Accidental Death 

4 

CIRCUMSTANCES OF THE DEATH 

EM was a 90 years old, fairly independent, lady who had some mobility issues but was 
able to get out and about in the community on a mobility scooter, coupled with the use of 
a walking stick.   

On 09.09.25 EM can be seen on CCTV footage arriving outside the PK Convenience 
Store, 25 Croft Bank Road, Urmston.  The said store is owned by SAI SKN Ltd.  EM can 
be seen getting off her mobility scooter and with a walking stick in hand attempts to 
enter the store, when she falls striking her head.  

The store has, at its entrance, a metal ramp said to be present to enable access for 
wheel users.  The width of the ramp is door-width and it is circa half that in depth, which 
makes quite a slope.  The ramp is not fixed to the ground as it is removed each night.  
On top of the ramp is a rubber mat which is not fixed to the ramp.  There are no 
handrails on the outside of the door frame.  The handrails, I was told, are about 6-9 
inches inside the doorway.   

The CCTV shows EM stepping on to the ramp one foot at a time. As she attempts to 
move off the ramp into the store she holds on to the door frame, it seems that the 
handrails are too far away. As she does this she appears to lose her balance and then 
the rubber mat moves, although it may be that the mat moves first, at this point she is 
unable to steady herself holding on to the door frame with one hand and falls to the 
ground.   

I understand that this incident was reported to you.  I have no doubt that you would have 

1 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 requested sight of the CCTV footage.   

5 

CORONER’S CONCERNS 

The evidence, today, of your store supervisor 
exactly as it was on the day of EM’s fatal accident.  
It is my opinion that the structure/design of the ramp makes it unsafe.  In particular that 
the ramp itself is not fixed or secured to the ground (not even semi-fixed so that it can be 
removed at the end of the day), that the rubber mat is not fixed and can easily move (as 
seen), there are no external easily accessible handrails, and the ramp is too short 
making the slope steeper.  

 was that the ramp remains 

The issue of concern is that unless action is taken to render access to the store by way 
of a safer design of ramp then there is a high risk of a customer, particularly a customer 
with mobility issues, suffering a similar and fatal fall as EM.    

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent the risk of 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 
22nd 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 Persons 
namely, who may find it useful or of interest. 

I have sent a copy to EM’s family.   
I have sent a copy to 
Services Department.   

, Health & Safety, Trafford MBC Regulatory 

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 

Andrew Bridgman 
HM Assistant Coroner 

27/03/2026 

2

Responses

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.

Response from Sai Skn Ltd (PDF)
To

Andrew Bridgman

HM assistant Coroner

Coroner’s court

1 Mount Tabor Street

Stockport SK1 3AG

' 

Received

0 6 MAY  2026

HM Coroner’s Office

Date : 30.04.2026

Dear Mr Bridgman,

Re: Regulation 28 Report to Prevent Future Deaths -  Edith Millington

We write in response to your Regulation 28 Report dated 27 March 2026.

First and foremost, we would like to express our sincere condolences to the family of

Mrs Edith Millington. We are deeply saddened by the circumstances of her death and

have carefully considered the concerns raised within your report. We can confirm that

this is first and last incident happened since we took overthe business and the access

was installed by previous owners of the business and not aware of any incidents

happening or noted any concerns with access by any customers.

Following a full review of the incident and the issues identified, with further consultation

and input from 

 from Trafford Council we have taken immediate

corrective action in respect of the entrance to our premises.

Specifically:

(cid:127)  The metal access ramp referenced in your report has been completely

removed.

(cid:127)  The entrance has been restructured to eliminate the previous ramp

arrangement and replaced with a small, stable step.

(cid:127)  Additional fixed grab rails have been installed on both sides of the entrance

to provide improved support and stability for customers entering and exiting

the store.

Warning signs in place to remind about the step and reflectors have been sticked

on the wall to warn customers about the step.

 These changes have been implemented to ensure a safer and more secure access point

for all customers, particularly those with mobility difficulties. We believe these

measures directly address the risks identified in your report regarding instability,

gradient, and lack of accessible handholds.

We remain committed to maintaining a safe environment for all customers and will

continue to review our premises and procedures to ensure appropriate safety standards

are upheld.

Please do not hesitate to contact us should you require any further information or wish

to discuss the action taken.

Yours sincerely.

Directors

SAI SKN LIMITED

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