Source · Prevention of Future Deaths
John Darling
Ref: 2015-0037
Date: 3 Feb 2015
Coroner: John Matthews
Area: Isle of Wight
Responses identified: 0 / 3
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An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.
Date
3 Feb 2015
56-day deadline
31 Mar 2015
Responses identified
0 of 3
Coroner's concerns
An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.
View full coroner's concerns
_ dogs: top
The "Off The Rails Cafe" has a platform which has an unguarded edge with a drop of approximately a metre onto the area where the railway track used to be_ Whilst there is painted warning on the ground at the point of the edge, am concerned that this is an accident which is almost inevitably going to reoccur as there is nothing to stop anyone over the edge: painted warning sign on the platform edge warning of the danger is of no use to those who are in baby buggies, or to toddlers or small children who may easily fall off the edge, or to someone who accidentally walks back over the edge am concerned that at times, it would be all too easy for someone to lose their footing and stumble off the edge of the platform. Whilst the manager of the Cafe gave evidence that more staff would be employed to usher patrons to their seats, it should be mentioned that this incident did not occur because of a lack of staff; but because of the unguarded platform edge: am further concerned by the slight incline on the platform towards the edge, which is visible on the plans, which was instituted to make it easier for disabled patrons to enter the Cafe and to avoid the necessity for a step into the premises_ The slight incline would increase the risk of a buggy or wheelchair leaving the premises being able to pick up speed and head directly towards the edge of the platform It should be mentioned that the Isle of Wight Council Planning Department had not requested that physical measures in the form of a barrier or balustrade be implemented to protect patrons from falling off the edge of the platform, notwithstanding that there had been three objections (later withdrawn) from members of the public at the Planning and Licensing Consultation stage_ Clearly, with the Cafe open for less than 2 months before this fatality occurred the position adopted by the Isle of Wight Planning Department Is untenable and needs to be reviewed,
The "Off The Rails Cafe" has a platform which has an unguarded edge with a drop of approximately a metre onto the area where the railway track used to be_ Whilst there is painted warning on the ground at the point of the edge, am concerned that this is an accident which is almost inevitably going to reoccur as there is nothing to stop anyone over the edge: painted warning sign on the platform edge warning of the danger is of no use to those who are in baby buggies, or to toddlers or small children who may easily fall off the edge, or to someone who accidentally walks back over the edge am concerned that at times, it would be all too easy for someone to lose their footing and stumble off the edge of the platform. Whilst the manager of the Cafe gave evidence that more staff would be employed to usher patrons to their seats, it should be mentioned that this incident did not occur because of a lack of staff; but because of the unguarded platform edge: am further concerned by the slight incline on the platform towards the edge, which is visible on the plans, which was instituted to make it easier for disabled patrons to enter the Cafe and to avoid the necessity for a step into the premises_ The slight incline would increase the risk of a buggy or wheelchair leaving the premises being able to pick up speed and head directly towards the edge of the platform It should be mentioned that the Isle of Wight Council Planning Department had not requested that physical measures in the form of a barrier or balustrade be implemented to protect patrons from falling off the edge of the platform, notwithstanding that there had been three objections (later withdrawn) from members of the public at the Planning and Licensing Consultation stage_ Clearly, with the Cafe open for less than 2 months before this fatality occurred the position adopted by the Isle of Wight Planning Department Is untenable and needs to be reviewed,
Report sections
Investigation and inquest
On September 2014 commenced an investigation into the death of John Ramsay Darling, aged 84. The investigation concluded at the end of the inquest on January 2015. The conclusion of the inquest was "Accidental Death" . The medical cause of death was found to be: 1a Cardiac Arrest Acute Cardiac Failure 1b External Bleeding Traumatic Injuries to Forehead and Nose 1c Ischaemic Heart Disease with Stenosing Atherosclerosis of Coronary Arteries and Myocardial Scar:
Circumstances of the death
1) John Ramsay Darling was born on 14"h August 1930. At the time of death, he was 84 years of age_
2) At the time of his death; he had a number of significant health issues, including atrial fibrillation and chronic cardiac failure. He was wheelchair bound due to his osteo-arthritis and was fitted with long-term catheter, He had spent considerable period on hospital;, from January 2013 before continuing his the 27th 27th from the his convalescence in a rehab nursing home: With medication, his condition had stabilised
3) On Saturday 27th September 2014, sometime after 12.30 p.m_ Mr Darling left his house with his daughter grand-daughter, and two family dogs They went for lunch to the "Off The Rails Cafe" in Station Road, Yarmouth; Isle of Wight;, which had opened for business on 4t August 2014. This Cafe was situated in a newly restored railway station on a disused line_ There were no railway tracks remaining below the platform, only a pathway cycle track:
4) Mr Darling; his daughter and grand-daughter chose to sit at a round table on the old rail platform outside the Cafe. They enjoyed a meal together, and consumed water with their meal. The Cafe was very busy whilst they were there.
5) Upon finishing their meal, moved her father's wheelchair out from under the table and positioned him to face towards the Tennyson Monument which was just off-parallel with the edge of the platform then turned away from her father to untie the She gave them to her daughter and told her to walk them away from other patrons with dogs. As she turned back to face her father; she saw his wheelchair moving over the edge of the platform. Mr Darling was still seated in his wheelchair as it rolled over the edge. The drop from the edge of the platform to the ground below was approximately a metre. There were no barriers to prevent this situation from occurring: rushed to her father's aid. He was found to be lying on his side with his face on the path below the edge of the platform He was bleeding from head injury: He was unresponsive and pale.
8) The Fire Brigade attended approximately 5 minutes later and were joined by an Ambulance. First aid and CPR was administered: was aware that there was a DNACPR in place for her father after his last heart attack
9) Mr Darling was taken to hospital by Ambulance He did not recover consciousness and was pronounced dead by Advance Nurse Practitioner Shane Moody at 16.48 hours on 27th September 2014.
2) At the time of his death; he had a number of significant health issues, including atrial fibrillation and chronic cardiac failure. He was wheelchair bound due to his osteo-arthritis and was fitted with long-term catheter, He had spent considerable period on hospital;, from January 2013 before continuing his the 27th 27th from the his convalescence in a rehab nursing home: With medication, his condition had stabilised
3) On Saturday 27th September 2014, sometime after 12.30 p.m_ Mr Darling left his house with his daughter grand-daughter, and two family dogs They went for lunch to the "Off The Rails Cafe" in Station Road, Yarmouth; Isle of Wight;, which had opened for business on 4t August 2014. This Cafe was situated in a newly restored railway station on a disused line_ There were no railway tracks remaining below the platform, only a pathway cycle track:
4) Mr Darling; his daughter and grand-daughter chose to sit at a round table on the old rail platform outside the Cafe. They enjoyed a meal together, and consumed water with their meal. The Cafe was very busy whilst they were there.
5) Upon finishing their meal, moved her father's wheelchair out from under the table and positioned him to face towards the Tennyson Monument which was just off-parallel with the edge of the platform then turned away from her father to untie the She gave them to her daughter and told her to walk them away from other patrons with dogs. As she turned back to face her father; she saw his wheelchair moving over the edge of the platform. Mr Darling was still seated in his wheelchair as it rolled over the edge. The drop from the edge of the platform to the ground below was approximately a metre. There were no barriers to prevent this situation from occurring: rushed to her father's aid. He was found to be lying on his side with his face on the path below the edge of the platform He was bleeding from head injury: He was unresponsive and pale.
8) The Fire Brigade attended approximately 5 minutes later and were joined by an Ambulance. First aid and CPR was administered: was aware that there was a DNACPR in place for her father after his last heart attack
9) Mr Darling was taken to hospital by Ambulance He did not recover consciousness and was pronounced dead by Advance Nurse Practitioner Shane Moody at 16.48 hours on 27th September 2014.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
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Report details
- Reference
- 2015-0037
- Date of report
- 3 February 2015
- Coroner
- John Matthews
- Coroner area
- Isle of Wight
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Mar 2015.
Sent to
- Isle of Wight Council
- Off the Rails Cafe
- Owner of the "Off The Rails Café" site