Source · Prevention of Future Deaths

Dorothy Gamby

Ref: 2025-0218 Date: 8 May 2025 Coroner: Melanie Lee Area: Inner North London Responses identified: 1 / 1 View PDF

Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.

Date 8 May 2025
56-day deadline 3 Jul 2025 est.
Responses identified 1 of 1
Product related deaths

Coroner's concerns

AI summary
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.
View full coroner's concerns
Wide and clawed ferrules for walking sticks are widely available. They are described as providing stability, support, improved safety, ease of movement, etc. I am concerned that there is no warning that they may pose a risk if stood on or trapped when used on folding/collapsible walking sticks.

Responses

1 respondent
Office for Product Safety and Standards Other
PDF
Action Planned

OPSS is working with the MHRA to ensure stakeholders involved in the supply of walking sticks are made aware of the incident and requested to review their risk assessments through contact with the British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers. (AI summary)

View full response
Dear Ms Lee, Regulation 28: Prevention of Future Deaths Report, Ms Dorothy Gamby Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 30 April 2025, concerning the death of Dorothy Gamby, following a fall Ms Gamby suffered when she stood on a wide claw ferrule attached to a foldable walking stick. I am responding in my role as Chief Executive of the Office for Product Safety and Standards (OPSS). I was very sorry to hear of Ms Gamby’s death. If you have the opportunity, please pass on my sympathies to her family and friends. OPSS is the UK’s product regulator, responsible for the regulation of most consumer products. The regulation of medical devices, which include walking sticks supplied for a medical purpose, is led by the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA has confirmed that walking sticks specifically intended by the manufacturer to provide medical assistance, such as mobility support for elderly or disabled individuals, or are marketed for the compensation of a disability or injury, are classified as medical devices. Such walking sticks fall under the regulatory oversight of the MHRA. As we do not have evidence regarding the specific product in this case, the intended purpose of the walking stick when it was placed on the market is unknown. Where they are not regulated under more specific regulations, consumer products such as ferrules are covered by the General Product Safety Regulations 2005 (GPSR). These require that all consumer products placed on the UK market must be safe. They place responsibility for product safety onto producers, which includes UK businesses manufacturing goods or importing products from overseas. In addition, distributors have a duty of care to not supply products they know, or should know, are unsafe.

Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201

The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss

In determining the safety of a product under GPSR, regard is given to the presentation of the product, including its labelling, warnings and instructions related to the normal and foreseeable conditions of use. To comply with GPSR and be a safe product, the producer must consider the risks posed by their product during foreseeable use and determine whether a warning label, information or other material can sufficiently mitigate those risks. From your report, it appears the hazard occurred when the ferrule was used in combination with a specific style of walking stick capable of folding or collapsing. Where large ferrules are supplied for the specific purpose of being attached to foldable or collapsible medical devices, it is reasonably foreseeable that this hazard may occur, and I would agree with you that warnings should be provided. Unfortunately, I have not received any evidence regarding the specific product that would enable us to determine whether such warnings were present in this case. I would be grateful if you would be able to share further details about the product that was involved in the incident. I have asked my team to work with the MHRA to ensure stakeholders involved in the supply and provision of walking sticks are made aware of this incident and requested to review their risk assessment through contact with British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers alongside medical devices, and any products designed to be attached to them. Thank you again for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with colleagues who may find it useful.

Kind regards,

Chief Executive OPSS

Report sections

Investigation and inquest
On 2 May 2025 an investigation into the death of Dorothy Gamby age 100 years. The investigation concluded at the end of the inquest on 8 May 2025. The medical cause of death was 1a. pneumonia 1b. fractured neck of femur (operated 22 April 2025). I made a determination at inquest of accident.
Circumstances of the death
Dorothy Gamby was 100 years old. On 22 April 2025 she suffered a fall at home when she stood on the wide claw shaped rubber ferrule that she had attached to the bottom of her foldable walking stick. This caused the stick to pull apart and the collapsible mechanism to activate when she pulled the stick up (the bottom section of the stick being held down by her foot on the ferrule). When she fell, she sustained fractures to her right hip and right wrist, and a small subarachnoid haemorrhage. On 22 April she underwent surgery for her hip fracture. Post-operatively she developed progressive hypoxia and Type 2 respiratory failure, secondary to known COPD. A chest xray on 25 April showed pneumonia which was treated with antibiotics. Despite this she continued to deteriorate, and given her frailty and co-morbidities, her care switched to palliative care and she died at the Whittington Hospital on 30 April 2025.

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Report details

Reference
2025-0218
Date of report
8 May 2025
Coroner
Melanie Lee
Coroner area
Inner North London

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jul 2025 (estimated).

Sent to

Office for Product Safety and Standards

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