Darlington Borough Council
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Dear Sir
Response to Prevention of Future Deaths Report
1. Coroner and Case Details Coroner: Rebecca Sutton, Senior Coroner/Assistant Coroner for the coroner area of County Durham and Darlington
Deceased: Susan Elizabeth SAMSON (DOB 10th April 1947)
Date of Death: 7th May 2025
Inquest Conclusion: Narrative conclusion [On 7 May 2025 at her home address in Darlington, the deceased died due to an accidental fall down the stairs. The death was caused by an accident, which was contributed to by an unsafe discharge home from a rehabilitation placement]
Date Prevention of Future Deaths Report Issued: 2nd March 2026
2. Organisation Responding Organisation Name: Darlington Borough Council
Address: Darlington Borough Council, Town Hall, Feethams, Darlington, DL1 5QT
Relevant Service: The Chief Executive
3. Summary of Coroner’s Concerns
CHIEF EXECUTIVE’S OFFICE Town Hall, Darlington DL1 5QT
H.M. Coroners Office P.O. Box 274 Stanley County Durham DH8 1HG
27th April 2026
This document was classified as: OFFICIAL The Prevention of Future Deaths Report identified the following matters of concern:
1. On 18 March 2025 (via an email timed at 16:19) a request was made by staff at Sedgefield Community Hospital to Darlington Borough Council (who were the landlord of the property where the deceased lived) to fit a second banister rail in the deceased’s home.
2. On 10 April 2025 a further request, by an Occupational Therapist working at the Rydal Care Home, was made to Darlington Borough Council to fit a second banister rail in the deceased’s home.
3. An appointment was made to fit the second banister in the deceased’s home on 6 May 2025.
4. For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025. I am concerned by the length of time between the requests for a second banister and the first appointment arranged to fit a second banister. I am concerned that, if similar circumstances arose today, or in the future, a Darlington Borough Council tenant could be exposed to a potentially avoidable risk of death while awaiting the installation of a second banister.
4. Action Taken or Proposed in Response to the Coroner’s Concerns The Council takes the coroner’s concerns extremely seriously. The following actions have been taken and/or are planned to address the concern:
Concern: Delay in responding to requests for minor works/adaptations at council owned property The Council has in place a process for dealing with any works/adaptations to Council owned properties. There is a guide for council tenants. This process is underpinned by a referral form which is to be sent to a manned email inbox for all proposed works.
It is anticipated that works/adaptations such as those required at Susan Samson’s property would usually be completed within 4 weeks. However, wherever possible works/adaptations will be completed within a timescale suitable to all and dependent upon any specific circumstances.
In respect of the observation/concern of the Coroner ‘For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025’. The timeline for the works is as set out in the statement and exhibits of Claire Gardner-Queen dated 26th February 2026. Unfortunately, the Council has not had sight of the email from Sedgefield Community Hospital which was purported to have been sent on 18th March 2025 and we are unable to ascertain whether the email was sent to the correct email address and whether it contained the referral form as required. Email correspondence from the OT from CDDFT indicates that she first made the referral for the second banister on 10th April 2025 and her referral form omitted the date on when Susan Samson would be fit for discharge. The OT had not received a response to that referral, and she contacted an officer of the Council on 28th April 2025 in respect of that referral. The OT advised that there was no one home at the property and gave details as to when Susan Samson was planned on being discharged home, this was planned for 1st May
2025. The works/adaptations were unable to be carried out prior to Susan Samson’s discharge home as there was no one at the property to permit access. Following communication between
This document was classified as: OFFICIAL a Council officer and the OT the works/adaptations which were originally scheduled for 14th May 2025 were brought forward to 6th May 2025 and the OT was advised of this date. The Council can confirm that the works were scheduled to be undertaken on 6th May 2025 and an attempt to install the second banister and grabrails was made on that day, but Susan Samson refused access to her property advising it was not convenient for the banister to be installed. As Susan Samson was a capacitated adult, she was within her rights to refuse access, and the Council was unable to lawfully enter and carry out the works in the absence of her consent.
The Council has reviewed the guide for tenants and are satisfied that there are no changes required to this document.
The referral form and email inbox for receipt of such referral forms remain appropriate, however, the Council intends to raise awareness of the referral process to ensure that all referrals are dealt with in a timely manner and that any queries in relation to the referral form are raised at the earliest opportunity to avoid any delay.
This case will be used as part of that awareness raising to ensure there is appropriate learning.
Random sampling audits will be carried out of the referrals. Should the content of the referrals be of concern then a review of that form will be considered and reissued.
5. How These Actions Will Reduce the Risk of Future Deaths
The action outlined above aims to strengthen and raise awareness of the process for works/adaptations to be completed in respect of council owned properties. This awareness will be raised both internally and with external stakeholders, in particular health colleagues.
It is anticipated that such awareness will improve the level of detail contained within referrals and communications and that such measures will reduce the likelihood of any repeat cases of individuals being discharged home without appropriate work/adaptations being carried out prior to or shortly after a discharge back home, thereby reducing the risk of potentially avoidable deaths in similar circumstances.
6. Ongoing Monitoring and Review Progress against this action will be reviewed by the Council, and any deficiencies will be addressed promptly. Learning from this case will also be shared through briefings within relevant departments [Housing, Adult and Childrens Social Care].
7. Declaration I confirm that the information provided in this response is accurate to the best of my knowledge and that the actions described have been, or will be, implemented as stated. Name: Rose Rouse Job Title: Chief Executive Organisation: Darlington Borough Council Date: 27 April 2026
This document was classified as: OFFICIAL
Should the Council be able to assist any further please do not hesitate to contact myself where I will endeavour to assist wherever possible.
Response to Prevention of Future Deaths Report
1. Coroner and Case Details Coroner: Rebecca Sutton, Senior Coroner/Assistant Coroner for the coroner area of County Durham and Darlington
Deceased: Susan Elizabeth SAMSON (DOB 10th April 1947)
Date of Death: 7th May 2025
Inquest Conclusion: Narrative conclusion [On 7 May 2025 at her home address in Darlington, the deceased died due to an accidental fall down the stairs. The death was caused by an accident, which was contributed to by an unsafe discharge home from a rehabilitation placement]
Date Prevention of Future Deaths Report Issued: 2nd March 2026
2. Organisation Responding Organisation Name: Darlington Borough Council
Address: Darlington Borough Council, Town Hall, Feethams, Darlington, DL1 5QT
Relevant Service: The Chief Executive
3. Summary of Coroner’s Concerns
CHIEF EXECUTIVE’S OFFICE Town Hall, Darlington DL1 5QT
H.M. Coroners Office P.O. Box 274 Stanley County Durham DH8 1HG
27th April 2026
This document was classified as: OFFICIAL The Prevention of Future Deaths Report identified the following matters of concern:
1. On 18 March 2025 (via an email timed at 16:19) a request was made by staff at Sedgefield Community Hospital to Darlington Borough Council (who were the landlord of the property where the deceased lived) to fit a second banister rail in the deceased’s home.
2. On 10 April 2025 a further request, by an Occupational Therapist working at the Rydal Care Home, was made to Darlington Borough Council to fit a second banister rail in the deceased’s home.
3. An appointment was made to fit the second banister in the deceased’s home on 6 May 2025.
4. For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025. I am concerned by the length of time between the requests for a second banister and the first appointment arranged to fit a second banister. I am concerned that, if similar circumstances arose today, or in the future, a Darlington Borough Council tenant could be exposed to a potentially avoidable risk of death while awaiting the installation of a second banister.
4. Action Taken or Proposed in Response to the Coroner’s Concerns The Council takes the coroner’s concerns extremely seriously. The following actions have been taken and/or are planned to address the concern:
Concern: Delay in responding to requests for minor works/adaptations at council owned property The Council has in place a process for dealing with any works/adaptations to Council owned properties. There is a guide for council tenants. This process is underpinned by a referral form which is to be sent to a manned email inbox for all proposed works.
It is anticipated that works/adaptations such as those required at Susan Samson’s property would usually be completed within 4 weeks. However, wherever possible works/adaptations will be completed within a timescale suitable to all and dependent upon any specific circumstances.
In respect of the observation/concern of the Coroner ‘For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025’. The timeline for the works is as set out in the statement and exhibits of Claire Gardner-Queen dated 26th February 2026. Unfortunately, the Council has not had sight of the email from Sedgefield Community Hospital which was purported to have been sent on 18th March 2025 and we are unable to ascertain whether the email was sent to the correct email address and whether it contained the referral form as required. Email correspondence from the OT from CDDFT indicates that she first made the referral for the second banister on 10th April 2025 and her referral form omitted the date on when Susan Samson would be fit for discharge. The OT had not received a response to that referral, and she contacted an officer of the Council on 28th April 2025 in respect of that referral. The OT advised that there was no one home at the property and gave details as to when Susan Samson was planned on being discharged home, this was planned for 1st May
2025. The works/adaptations were unable to be carried out prior to Susan Samson’s discharge home as there was no one at the property to permit access. Following communication between
This document was classified as: OFFICIAL a Council officer and the OT the works/adaptations which were originally scheduled for 14th May 2025 were brought forward to 6th May 2025 and the OT was advised of this date. The Council can confirm that the works were scheduled to be undertaken on 6th May 2025 and an attempt to install the second banister and grabrails was made on that day, but Susan Samson refused access to her property advising it was not convenient for the banister to be installed. As Susan Samson was a capacitated adult, she was within her rights to refuse access, and the Council was unable to lawfully enter and carry out the works in the absence of her consent.
The Council has reviewed the guide for tenants and are satisfied that there are no changes required to this document.
The referral form and email inbox for receipt of such referral forms remain appropriate, however, the Council intends to raise awareness of the referral process to ensure that all referrals are dealt with in a timely manner and that any queries in relation to the referral form are raised at the earliest opportunity to avoid any delay.
This case will be used as part of that awareness raising to ensure there is appropriate learning.
Random sampling audits will be carried out of the referrals. Should the content of the referrals be of concern then a review of that form will be considered and reissued.
5. How These Actions Will Reduce the Risk of Future Deaths
The action outlined above aims to strengthen and raise awareness of the process for works/adaptations to be completed in respect of council owned properties. This awareness will be raised both internally and with external stakeholders, in particular health colleagues.
It is anticipated that such awareness will improve the level of detail contained within referrals and communications and that such measures will reduce the likelihood of any repeat cases of individuals being discharged home without appropriate work/adaptations being carried out prior to or shortly after a discharge back home, thereby reducing the risk of potentially avoidable deaths in similar circumstances.
6. Ongoing Monitoring and Review Progress against this action will be reviewed by the Council, and any deficiencies will be addressed promptly. Learning from this case will also be shared through briefings within relevant departments [Housing, Adult and Childrens Social Care].
7. Declaration I confirm that the information provided in this response is accurate to the best of my knowledge and that the actions described have been, or will be, implemented as stated. Name: Rose Rouse Job Title: Chief Executive Organisation: Darlington Borough Council Date: 27 April 2026
This document was classified as: OFFICIAL
Should the Council be able to assist any further please do not hesitate to contact myself where I will endeavour to assist wherever possible.