October 28, 2025

Ann Campbell: Prevention of future deaths report

Other related deaths

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Date of report: 23/10/2025

Ref: 2025-0535

Deceased name: Ann Campbell

Coroner name: Andrew Cox

Coroner Area: Cornwall and the Isles of Scilly

Category: Other related deaths

This report is being sent to: Landlord

	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) 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: [REDACTED], 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	23/10/25