Frederick Powell: Prevention of future deaths report
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Date of report: 24/10/2023
Ref: 2023-0406
Deceased name: Frederick Powell
Coroner name: Paul Cooper
Coroner Area: Lincolnshire
Category: Other related deaths
This report is being sent to: Acis Housing
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 Acis HOUSING | |
| 1 | CORONER I am Paul COOPER, HM Assistant Coroner for the coroner area of Lincolnshire |
| 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 12 September 2023 I commenced an investigation into the death of Frederick POWELL aged 93. The investigation concluded at the end of the inquest on 24 October 2023. The conclusion of the inquest was that: The deceased died on 6th September 2023 at 20 St.Martins Close, Blyton , Gainsborough when he fell through a glass door at home suffering life threatening injuries that he failed to recover from. |
| 4 | CIRCUMSTANCES OF THE DEATH The deceased died on 6th September 2023 at 20 St.Martins Close, Blyton , Gainsborough when he fell through a glass door at home suffering life threatening injuries that he failed to recover from. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) Although it is not suggested current building regulations were breached the Inquest was told many more properties in your stock retained internal glass doors. Is it time for a review to reconsider replacement ? |
| 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 December 19, 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 Persons I have also sent it to Acis HOUSING who may find it useful or of interest. 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 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 by the Chief Coroner. |
| 9 | 24/10/2023 Paul COOPER, HM Assistant Coroner for Lincolnshire |