Source · Prevention of Future Deaths

Elizabeth Bury

Ref: 2024-0480 Date: 28 Aug 2024 Coroner: Emma Serrano Area: Staffordshire Responses identified: 1 / 1 View PDF

The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.

Date 28 Aug 2024
56-day deadline 16 Oct 2024
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
View full coroner's concerns
1. That this carpark has been the source of many falls because of the speed bumps.

Responses

1 respondent
Staffordshire Moorlands District Council Local Authority / Fire Service
PDF
Action Planned

Staffordshire Moorlands District Council will replace the speed bumps closest to the incident location with a larger, flat-topped speed bump, painted as a zebra crossing and will investigate additional signage in the interim. (AI summary)

View full response
Dear Coroner, Response to Prevention of Future Deaths Report. We acknowledge receipt of the Prevention of Future Deaths report, issued following the inquest into the death of Elizabeth Margaret Bury on 13th August 2024. The Council wishes to express its sadness and concern upon reading the details in the report. Please be reassured that we take these matters very seriously indeed, and we are grateful for the opportunity to set out the action we have taken to prevent future deaths. Overview of the Issue Raised In your report, you have identified that Tape Street Car Park, Cheadle, where the incident occurred, has been the source of many falls because of speed bumps. Actions Taken to Address the Concerns Since receiving your report, we have undertaken the following steps:
• The day after receiving your report the Council’s Corporate Health and Safety Manager visited the car park accompanied by a Senior Compliance Officer from the Council’s Assets team. The purpose of the visit was to assess the overall condition of the car park, including the traffic

2

calming measures currently in place. It was noted that the speed bumps were highlighted with white thermoplastic road marking paint which were in good condition and visible.
• On the 9th October 2024, a further inspection was undertaken by a representative from the British Car Parking Association, accompanied by a Council Officer and a Police Officer from Staffordshire Police. It was confirmed that the car park meets the ‘Park Mark’ scheme which establishes national safety standards. Notwithstanding the matters found during the site visit, the Council has carefully considered the content of your report and will action improvements to the car park as set out below. Ongoing Commitments The professional advice we have received has resulted in the following planned action:
• The Council will remove the speed bumps closest to where we understand the incident to have occurred. Subject to design advice, the current speed bumps will be replaced with a larger speed bump, with a flat top, which will adjoin the pedestrian platforms at either side. The top of the new speed bump will be painted to delineate a zebra crossing, and to provide a flat walking platform of consistent height all the way across between the two platforms. The Council will look to expedite the works and we expect to have them completed by the end of this year.

• In the interim period, the Council will investigate whether additional signage can be added to make pedestrians aware of speed bumps/uneven surfaces, and where and how these can be placed on site. We hope the steps outlined above demonstrate our commitment to preventing future deaths and our determination to address the matters identified in your report. Should you require any further information, or if you wish to discuss any part of our response in more detail, please do not hesitate to contact us. Once again, we offer our sincere condolences to the family of Ms Bury and assure you that we are taking all necessary steps to prevent any similar incident from occurring in the future.

Report sections

Investigation and inquest
On the 12 April 2024, I commenced an investigation into the death of Mrs Elizabeth Margaret Bury. The investigation concluded at the end of the inquest on 13 August 2024. The conclusion of the inquest was a narrative conclusion comprising of “complications following a fall.” The cause of death was: 1a Bilateral haemothorax due to rib fractures and cardiac laceration 1b Fall 1c II Ischaemic heart disease
Circumstances of the death
i) Mrs Bury was walking back to her care in Tape Street Carpark in Cheadle on the 15 February 2024. She fell on a speed bump in the car park. This caused bilateral haemothorax due to rib fractures and cardiac laceration. She passed away at the carpark.

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Report details

Reference
2024-0480
Date of report
28 August 2024
Coroner
Emma Serrano
Coroner area
Staffordshire

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: 16 Oct 2024.

Sent to

Staffordshire Moorlands District Council

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