Janet Harrison: Prevention of Future Deaths Report

Other related deaths

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Date of report: 05/08/2024 

Ref: 2024-0562 

Deceased name: Janet Harrison

Coroners name: Sunyana Sharma

Coroners Area: Hampshire, Southampton and Portsmouth

Category: Other related deaths 

This report is being sent to: Eastleigh Borough Council | Southampton City Council

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
 
Building Control Inspector, Eastleigh Borough Council
Building Control Inspector, Southampton City Council (as building control services are offered in partnership with Eastleigh Borough Council)
1CORONER
 
I am Sunyana SHARMA, Assistant Coroner, for the coroner area of Hampshire, Southampton and Portsmouth
2CORONER’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.
3INVESTIGATION and INQUEST
 
On 6 September 2022 I commenced an investigation into the death of Janet Karen HARRISON aged 76. The investigation concluded at the end of the inquest on1 July 2024. Janet Karen HARRISON died on 31 August 2022 in hospital from pneumonia following the collapse of her neighbour’s wall on 18 February 2022 for which she suffered from polytrauma.  The medical cause of death was confirmed as 1a. hospital acquired pneumonia, 1b. infected left gluteal haematoma, frailty, 1c. polytrauma and 2. hypertension, DVT and cholecystitis. The short-form conclusion reached was accident.
4CIRCUMSTANCES OF THE DEATH
 
On 18 February 2022, the UK was affected by Storm Eunice for which the Met Office had issued two severe weather warnings. In the area where Janet Karen HARRISON lived, the weather was reported to be wet and windy with gusts of around 50 to 60mph.  At approximately 12.10pm on 18 February 2022, Janet Karen HARRISON was found in her garden under her neighbour’s collapsed wall by her neighbour.  As a result of the accident, she suffered from life threatening and catastrophic injuries including multiple fractures.
 
Two admissions at Southampton General Hospital followed from 18 February 2022 to 31 March 2022 and from 14 April 2022 until her death on 31 August 2022 and a short admission to Romsey Rehabilitation hospital during the intervening period from 31 March 2022 to 14 April 2022 when Janet Karen HARRISON was deemed to be medically optimised.  During her first admission in the hospital she acquired deep vein thrombosis and hospital acquired pneumonia for which she was treated. In her second admission to Southampton General Hospital, she suffered from a bacterial infection and a gastrointestinal bleed for which she was treated. She continued to show signs of an infection in June and July 2022 and was treated for cholecystitis. She also suffered from left gluteal haematoma for which she was treated surgically on 8 August 2022 and 27 August 2022 due to ongoing concerns of infection.  She died on 31 August 2022 from hospital acquired pneumonia.

The Court heard evidence from [REDACTED], Head of the Structural team at Hampshire County Council who gave evidence that the wall was unsafe and should never have been built to a height of 1.95 metres given that it was a half brick wall.  The impact of the storm was worsened by the fact that a large surface area of fencing panel was attached to the wall which meant that it was susceptible to collapsing as the fencing panel acted as a sail when exposed to the winds from Storm Eunice thereby contributing to the wall coming down.  
5CORONER’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 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.  –
 
I heard evidence from [REDACTED], the owner of the property adjoining that of Janet Karen HARRISON whose wall collapsed on 18 February 2022, [REDACTED], the occupier and neighbour of Janet Karen HARRISON and the family of Janet Karen HARRISON who have all confirmed to me in evidence that there are a number of adjoining properties in the area which have walls built with the same unsafe dimensions as the one that collapsed on to Janet Karen HARRISON during Storm Eunice.  
 
I am therefore concerned that if there were other storms in the UK of similar force to that of Storm Eunice then there is a risk of further walls in the local area collapsing thereby placing others at risk of future deaths. 
6ACTION 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.
7YOUR RESPONSE
 
You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 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.
8COPIES and PUBLICATION
 
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the Family of Janet Karen HARRISON.  I have also sent it to [REDACTED] who may find it useful or of interest.
 
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.
95 August 2024                                             
[SIGNED BY CORONER]