Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0215, written 14 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Apr 2026 |
|---|---|
| Reference | 2026-0215 |
| Deceased | Catherine Oliver |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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:
The Chief Executive: Sanctuary Housing Association
1
CORONER
I am Nicholas Graham, Area Coroner for the Coroner area of Oxfordshire.
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 the 18 December 2025 I commenced an investigation into the death of
Catherine Oliver, aged 88 years. The investigation concluded following a hearing
on the 13 April 2026.
The conclusion of the Inquest was a short-form conclusion of accidental death, and
that Mrs Oliver died following complications arising after a fractured neck of femur
sustained in a fall at her home.
4
CIRCUMSTANCES OF THE DEATH
Mrs Oliver lived independently in a property owned by Sanctuary Housing.
In the weeks prior to her fall, contractors acting on behalf of Sanctuary Housing
carried out works on the property. In order to facilitate these works, items stored in
the loft were removed and placed in the living room of the property.
Evidence heard at the inquest established that:
• The boxes removed from the loft remained in Mrs Oliver’s living room for
nearly four weeks.
• During this period, Mrs Oliver and her family made requests for the boxes to
be removed, which were not acted upon.
• The boxes were stacked in an orderly manner but significantly reduced the
available space, leaving a narrow walkway within the living area.
This arrangement materially restricted Mrs Oliver’s ability to move safely around her
home.
Mrs Oliver fell in the living room on 8 December 2025 and was later found injured in
the confined space between her armchair and the stacked boxes.
It is not possible to determine whether the presence of the boxes caused Mrs
Oliver’s fall, and no such finding is made. However, the evidence demonstrated that
their prolonged presence created a mobility hazard within the property.
5
CORONER’S CONCERNS
During the course of the inquest, the following matters of concern arose.
(a) Hazard created by prolonged storage of household items
The storage of large quantities of boxed items within the main living area for an
extended period created a significant hazard, particularly for an elderly and
potentially vulnerable tenant.
(b) Lack of clear controls or time limits
There appeared to be no clear policy or instruction governing:
• how long household items may be stored within living areas as part of
necessary works; or
• what mitigating steps should be taken when such storage extends beyond a
minimal or short-term period.
(c) Risk to other tenants
In my view, if similar circumstances were to arise in other properties—particularly
those occupied by elderly, disabled or mobility-restricted tenants—there is a risk of
future deaths or serious injury arising from restricted movement or trip hazards.
6
ACTION SHOULD BE TAKEN
In my view, action should be taken to prevent future deaths, and I believe Sanctuary
Housing has the power to take such action.
7
YOUR RESPONSE
You are required to provide a written response to this report within 56 days of the
date of this report.
Your response should set out:
the action taken or proposed to be taken; or
•
• an explanation if no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and the deceased’s family.
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
14th April 2026 Mr N Graham
Area Coroner for Oxfordshire
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