Elsie Murphy: Prevention of future deaths report
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Date of report: 09/06/2023
Ref: 2023-0189
Deceased name: Elsie Murphy
Coroner name: Nicholas Shaw
Coroner Area: Cumbria
Category: Other related deaths
This report is being sent to: Cumberland Council
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Chief Executive, Cumberland Council, Carlisle | |
| 1 | CORONER I am Dr Nicholas Shaw, HM Assistant Coroner for Cumbria |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 30 September 2022 I commenced an investigation into the death of Elsie Mary MURPHY, aged 86. The investigation concluded at the end of the inquest . The conclusion of the inquest was Death due to an accident 1a Acute on-chronic sub-dural haemorrhage 1b 1c Fall II Anticoagulated for atrial fibrillation |
| 4 | CIRCUMSTANCES OF THE DEATH On 27th September 2022 Elsie was walking along the footpath from that leads from Windermere Road to Ewanrigg Road in Maryport to reach a bus stop. immediately below the steps leading up to Ewanrigg road the path turns 90 degrees right, Elsie slipped in a puddle that had formed here and fell, sustaining her fatal injury. She died in Cumberland Infirmary the following day. |
| 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. [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Evidence was heard that a puddle always forms at this location in wet weather and that people have slipped here in the past. Pictures taken on the evening Elsie fell were accepted in evidence and are attached. It seems that a drain or soak away from under Ewanrigg Road discharges down the grassy bank to the left of the steps looking up them and pools on the path. There is a drain on the right hand side of the path a few feet from the base of the steps but water does not seem to reach it. I am concerned that if this issue is not addressed by some remedial work further accidents will occur |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your council 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, 7 namely by 14th July 2023. 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 Person , Elsie’s daughter. 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 | 19 May 2023 Signature Dr Nicholas Shaw HM Assistant Coroner |