Fredrick Dunbavin
PFD Report
All Responded
Ref: 2024-0396
All 1 response received
· Deadline: 17 Sep 2024
Response Status
Responses
1 of 1
56-Day Deadline
17 Sep 2024
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. During the inquest evidence was heard that: i. There is open access from the carpark area at The Treetops Apartment complex to the wooded area that Mr Dunbavin accessed before he fell. In addition, there is no barrier between the edge of wooded area and the pathway that runs to the rear of the church hall. Finally, there is no signage to warn that there is a dangerous drop from the edge of the wooded area onto the path below.
2. I have concerns with regard to the following: i. Mr Dunbavin sustained multiple injuries following a fall from the wooded area at the Treetops Apartment complex, having accessed the wooded area from the parking area. There was nothing that prevented him from accessing this area, or warning him of the drop from the wooded area. I understand that no changes have been made subsequent to Mr Dunbavin’s death. Therefore, there remains a risk that access can be easily gained to this area, with a risk of life-threatening injuries should anyone fall from the wooded area to the path below.
2. I have concerns with regard to the following: i. Mr Dunbavin sustained multiple injuries following a fall from the wooded area at the Treetops Apartment complex, having accessed the wooded area from the parking area. There was nothing that prevented him from accessing this area, or warning him of the drop from the wooded area. I understand that no changes have been made subsequent to Mr Dunbavin’s death. Therefore, there remains a risk that access can be easily gained to this area, with a risk of life-threatening injuries should anyone fall from the wooded area to the path below.
Responses
Response received
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Dear Coroner RE: 35373940 Inquest on the death of Frederick Barrie Dunbavin Firstly, I would like to apologise for the late response in regards to this matter. The board of directors were awaiting legal advice around the responsibilities of the land in question which the company lease from BCP Council. The company has had a HHSRS assessment carried out. It was the assessor qualified opinion that it would be reasonable to extend the existing metal key clamp barrier along extent of the boundary to further deter access to the neighbouring public land. The Council is installing wire mesh along the bottom section of all metal key clamp barriers on site to further restrict anyone gaining access. In addition to the recommended works, signs advising ‘No Access & fall risk’ have also been installed. With regard the fall risk which is situated further in on the neighbouring public land, BCP Highways manages the site. It will be for the relevant officer in BCP Highways to consider how they are going to address/mitigate the fall risk. Here’s a picture of Seascapes boundary with the neighbouring public land to refresh, it shows the metal key clamp arrangement on the left which is being extended across the full length of the boundary to the right.
Report Sections
Investigation and Inquest
On the 14th December 2023, an investigation was commenced into the death of Frederick Barrie Dunbavin, born on the 30th June 1948.
The investigation concluded at the end of the Inquest on the 9th July 2024.
The Medical Cause of Death was:
1a Multiple Injuries
1b
1c
2 Complete Occlusion of the Left Coronary Artery
The conclusion of the Inquest recorded that Frederick Barrie Dunbavin died as a consequence of an accident.
The investigation concluded at the end of the Inquest on the 9th July 2024.
The Medical Cause of Death was:
1a Multiple Injuries
1b
1c
2 Complete Occlusion of the Left Coronary Artery
The conclusion of the Inquest recorded that Frederick Barrie Dunbavin died as a consequence of an accident.
Circumstances of the Death
Frederick Barrie Dunbavin, who was diagnosed with dementia and who experienced periods of confusion, fell from a wooded area in the grounds of the Treetop Apartments onto a concrete path that runs to the rear of the St Stephen’s church hall. As a consequence of the fall, Mr Dunbavin sustained multiple injuries, which caused his death. A police investigation revealed there is a low wooden fence separating the wooded area from a parking area at the apartment complex. However, there is a gap in the fence, allowing easy access to the woodland, and no barrier between the wooded area and the drop onto the path that runs to the rear of the church hall.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.