A coroner has said he will write to a council to express concerns over the state of Nottinghamshire's roads after a pedestrian tripped crossing the street and died. Beryl Barrett fell while crossing Church Street in Warsop on 19 December last year after a wheel in her walking frame became stuck in the road, leading to her losing balance and fracturing her hip.
The 87-year-old died six days later on Christmas Day, and an inquest at Nottingham Coroner's Court on Monday found her death was accidental. Assistant coroner Nathanael Hartley issued a prevention of future deaths report over concerns at how the county council and its contractor assess reported damage, and over national guidelines.
Barrett's family told the court she was a
"feisty" and "independent" womanwho was active in her church and the local community.
They said Barrett
"went out every day - she couldn't stand being in".
"She played bingo several times a week, went out with friends to Skegness. We had family holidays together,"they added.
"She was involved with the community and the church and local old people's places. She was active, she was fit, she kept herself going and she had no interest with any healthcare. Within days of coming out of hospital she'd be sacking carers as she said she could do it herself.
"Even going into hospital she was in good spirits. For us that's the worst bit. If she'd gone in because of her COPD [chronic obstructive pulmonary disorder] and just died it would've been the end naturally. We feel this wasn't a natural way to go."
The court heard Barrett died in hospital on Christmas Day, with a medical cause of death recorded as bronchopneumonia, with COPD, ischaemic heart disease, the fracture and diabetes among other contributory factors.
Recording a conclusion of accidental death, coroner Hartley said the fall
"along with other co-morbidities contributed to her death".
"The fall more than minimally contributed to Beryl's death, because without it she would not have died when she did,"he said.
Barrett fell while crossing Church Street in Warsop
Earlier this year, Labour MP Steve Yemm raised the issue of the state of Nottinghamshire's roads in Parliament, saying Barrett
"tragically fell into an unrepaired pothole".
The now former prime minister Sir Keir Starmer responded to the question by offering his
"deepest sympathies"to Barrett's family.
However, at Barrett's inquest, no mention of the specific type of road defect was made, with the coroner concluding that any defect
"was not actionable at the point of the fall".
The inquest was not told the depth or width of the road defect where Barrett's walking frame became stuck.
To be
"actionable", according to guidelines by the UK Roads Leadership Group, a defect must be 20mm deep if it is on a pavement or crossing, or 40mm deep if it is on a road.
The court heard inspections of the road had been carried out on 2 October, 3 November and 1 December that year, with no defects reported, but a re-examination of the video of the last inspection showed one of the defects on the pedestrian crossing that Barrett had used, which should have been flagged for repair.
A report was made to the council after Barrett's fall, and the road was inspected on 31 December before being repaired on 2 January.
Why did the highways contractor say the road was difficult to manage?
Steve Walton, pre-construction director for Via East Midlands - which provides highways services for Nottinghamshire County Council - said they were dealing with
"multiple thousands"of calls about the conditions of the road, which he said could deteriorate quickly due to the wet wintry weather.
He said an
"additional defect"in the road might have been present when Barrett was crossing, but said workers had followed the correct procedures with inspections and repairs.
"We were dealing with unprecedented levels of demand,"he said.
"There were a number of defects at the time which were not repaired during the KPI [key performance indicator] window."
What did the coroner say about future risks?
In his conclusion, Hartley said any defect
"was not actionable at the point of the fall", but said he would write to the county council and Via over concerns about not
"having a process in place that allows them to triage [calls] made to them"about the condition of the roads.
"I am concerned that there is a risk of future deaths to others,"he said.
Hartley said he would also write to the UK Roads Leadership Group about concerns there were
"no specific recommendations"in national codes of practice with regards to pedestrians using wheeled frames and similar aides.
Following the inquest's conclusion, David Langford - director of highways, transport and waste management at the council - said:
"Since this incident, we have been looking at the details of this case."
"Once we have received the letter of recommendations from the inquest, we will work with colleagues at Via to undertake a thorough review of our policies and procedures, and look at ways to make improvements which may help to avoid similar incidents occurring in the future."
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