August 1, 2024

Frederick Dunbavin: Prevention of Future Deaths Report

Other related deaths

Skip to related content

Date of report: 23/07/2024

Ref: 2024-0396

Deceased name: Fredrick Dunbavin

Coroner name: Brendan Allen

Coroner Area: Dorset

Category: Other related deaths

This report is being sent to: Seascape Homes and Property Limited

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: 1. [REDACTED], Director Seascape Homes and Property Limited
1	CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset
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 14^th December 2023, an investigation was commenced into the death of Frederick Barrie Dunbavin, born on the 30^th June 1948. The investigation concluded at the end of the Inquest on the 9^th July 2024. The Medical Cause of Death was: 1a Multiple Injuries 1b 1c 2 Complete Occlusion of the Left Coronary Artery The conclusion of the Inquest recorded that Frederick Barrie Dunbavin died as a consequence of an accident.
4	CIRCUMSTANCES OF THE DEATH Frederick Barrie Dunbavin, who was diagnosed with dementia and who experienced periods of confusion, fell from a wooded area in the grounds of the Treetop Apartments [REDACTED] onto a concrete path that runs to the rear of the St Stephen’s church hall. As a consequence of the fall, Mr Dunbavin sustained multiple injuries, which caused his death. A police investigation revealed there is a low wooden fence separating the wooded area from a parking area at the apartment complex. However, there is a gap in the fence, allowing easy access to the woodland, and no barrier between the wooded area and the drop onto the path that runs to the rear of the church hall.
5	CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: During the inquest evidence was heard that: i. There is open access from the carpark area at The Treetops Apartment complex to the wooded area that Mr Dunbavin accessed before he fell. In addition, there is no barrier between the edge of wooded area and the pathway that runs to the rear of the church hall. Finally, there is no signage to warn that there is a dangerous drop from the edge of the wooded area onto the path below. I have concerns with regard to the following: i. Mr Dunbavin sustained multiple injuries following a fall from the wooded area at the Treetops Apartment complex, having accessed the wooded area from the parking area. There was nothing that prevented him from accessing this area, or warning him of the drop from the wooded area. I understand that no changes have been made subsequent to Mr Dunbavin’s death. Therefore, there remains a risk that access can be easily gained to this area, with a risk of life-threatening injuries should anyone fall from the wooded area to the path below.
6	ACTION SHOULD BE TAKEN In my opinion urgent 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, by 17^th September 2024. 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: (1) [REDACTED] 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	Dated 23^rd July 2024 Brendan J Allen

Related content