Elizabeth Bury: Prevention of Future Deaths Report
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Date of report: 28/08/2024
Ref: 2024-0480
Deceased name: Elizabeth Bury
Coroners name: Emma Serrano
Coroners Area: Staffordshire
Category: Other related deaths
This report is being sent to: Staffordshire Moorlands District Council
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Staffordshire Moorlands District Council | |
| 1 | CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of Staffordshire |
| 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 12 April 2024, I commenced an investigation into the death of Mrs Elizabeth Margaret Bury. The investigation concluded at the end of the inquest on 13 August 2024. The conclusion of the inquest was a narrative conclusion comprising of “complications following a fall.” The cause of death was: 1a Bilateral haemothorax due to rib fractures and cardiac laceration 1b Fall 1c II Ischaemic heart disease |
| 4 | CIRCUMSTANCES OF THE DEATH i) Mrs Bury was walking back to her care in Tape Street Carpark in Cheadle on the 15 February 2024. She fell on a speed bump in the car park. This caused bilateral haemothorax due to rib fractures and cardiac laceration. She passed away at the carpark. |
| 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 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. That this carpark has been the source of many falls because of the speed bumps. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent 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, namely by 16 October 2024. 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: Family of the deceased; 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 | 28 August 2024 Miss Emma Serrano Area Coroner Staffordshire Area |