Maureen Gilbert: Prevention of future deaths report
Date of report: 08/09/2025
Ref: 2025-0456
Deceased name: Maureen Gilbert
Coroner name: Matthew Kewley
Coroner Area: Derby and Derbyshire
Category: Other related deaths
This report is being sent to:
- [REDACTED], Parliamentary Under-Secretary of State (Minister for Water and Flooding)
- [REDACTED] Executive Director at Derbyshire County Council
- [REDACTED] Chief Executive of the Environment Agency
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED], Parliamentary Under-Secretary of State (Minister for Water and Flooding) [REDACTED] Executive Director at Derbyshire County Council [REDACTED] Chief Executive of the Environment Agency | |
| 1 | CORONER I am Matthew Kewley, Assistant Coroner, for the coroner area of Derby and Derbyshire. |
| 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 26 October 2023 I commenced an investigation into the death of Maureen Gilbert who was 83 years old when she died on 21 October 2023. The investigation concluded at the end of the inquest on 5 September 2025. I concluded that Mrs Gilbert drowned in her own home due to flood waters caused by Storm Babet. |
| 4 | CIRCUMSTANCES OF THE DEATH Mrs Gilbert lived her entire life on Tapton Terrace in Chesterfield. Tapton Terrace runs along the banks of the River Rother. It consists of 26 houses in total. Tapton Terrace is known to be at risk of flooding. This is due to multiple factors including the presence of two other water sources that discharge into the River Rother just upstream of Tapton Terrace (namely the River Hipper and Spittle Brook) and the absence of flood defences at Tapton Terrace. In 2007 Tapton Terrace was badly damaged due to flooding. A pre-feasibility study commissioned by the Environment Agency in 2008 identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. However, none of these options were implemented as they were not considered to be cost effective. In 2018 the Avenue Flood Balance Reservoir became operational further upstream on the River Rother. This is a large water storage area on the River Rother which is designed to hold back water upstream with the aim of reducing water flow downstream. Also in 2018 Mrs Gilbert’s house was fitted with a number of property flood reduction measures such as front and rear door flood barriers to help protect against water ingress. These measures, however, only provided protection up to a water level height of 0.6m. On 20 October 2023 the River Rother burst its banks at Tapton Terrace. This was caused by significant levels of rainfall during Storm Babet. The river levels reached a record level. Despite the best efforts of the emergency services on 20 October 2023 Mrs Gilbert could not be rescued from her house on Tapton Terrace. On 21 October 2023 Mrs Gilbert was found deceased in her lounge. She had drowned as a result of the flood waters entering her property on Tapton Terrace. |
| 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. – · Following the flood damage to Tapton Terrace in 2007, the Environment Agency’s pre-feasibility study identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. None of these measures were implemented principally due to cost reasons. When Storm Babet hit in October 2023, Tapton Terrace remained in the same position that it was in back in 2007. Due to the ongoing lack of flood defences, Tapton Terrace remains vulnerable to flooding. I am concerned that this gives rise to a risk to life, particularly in respect of residents who may be elderly, vulnerable or immobile. |
| 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 3 November 2025. 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: · [REDACTED] Parliamentary Under-Secretary of State (Minister for Water and Flooding) · [REDACTED] Executive Director at Derbyshire County Council · [REDACTED] Chief Executive of the Environment Agency I have also sent it to the following individuals who may find it of interest: · [REDACTED] Derbyshire Fire and Rescue · [REDACTED] Chesterfield Borough Council · [REDACTED] MP for Chesterfield 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. She may send a copy of this report to any person who she 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 | [REDACTED] Matthew Kewley Assistant Coroner for Derby and Derbyshire 8 September 2025 |