Maureen Gilbert

PFD Report All Responded Ref: 2025-0456
Date of Report 8 September 2025
Coroner Matthew Kewley
Response Deadline est. 3 November 2025
All 3 responses received · Deadline: 3 Nov 2025
Coroner's Concerns (AI summary)
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to life, especially for residents.
View full coroner's concerns
• Following the flood damage to Tapton Terrace in 2007, the Environment Agency’s pre-feasibility study identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. None of these measures were implemented principally due to cost reasons. When Storm Babet hit in October 2023, Tapton Terrace remained in the same position that it was in back in 2007. Due to the ongoing lack of flood defences, Tapton Terrace remains vulnerable to flooding. I am concerned that this gives rise to a risk to life, particularly in respect of residents who may be elderly, vulnerable or immobile.
Responses
Derbyshire County Council Local Authority / Fire Service
8 Sep 2025
Action Planned
Derbyshire County Council is exploring the feasibility of removing an access bridge to reduce flood risk and constructing a Flood Alleviation Scheme on the Spital Brook. They will also continue to work collaboratively with the Environment Agency to encourage residents to sign up for flood warnings and review existing flood plans and evacuation procedures. (AI summary)
View full response
CONTROLLED RESPONSE TO REGULATION 28 NOTICE FROM DERBYSHIRE COUNTY COUNCIL This is the response to the Regulation 28 Report to Prevent Future Deaths issued by Coroner for Derbyshire and Derby, Matthew Kewley dated 8th September 2025. Derbyshire County Council (“DCC”) in its capacity as Lead Local Flood Authority (Floods and Water Management Act 2010) has the lead responsibility for managing local flood risk , from surface water, groundwater and ordinary watercourses. The Environment Agency is responsible for taking a strategic overview of the management of all sources of flooding and coastal erosion. Although the primary responsibility for managing flood risk from main rivers, (of which the River Rother at Tapton Terrace, Chesterfield is) vests with the Environment Agency (“EA”) DCC continue to work collaboratively with the EA to explore ways in which the flood risk can be reduced in order to avoid the risk to life. DCC is currently exploring the feasibility of removing an access bridge, which is located over the River Rother, just to the south of Tapton Terrace. The access bridge is public highway and is the responsibility of the authority to manage and maintain. Removal of the access bridge may provide a benefit in terms of reducing the flood risk to Tapton Terrace and surrounding flood areas. There would be a requirement to utilise the EA’s modelling and expertise, in order to evidence that removal of the bridge will actually reduce the flood risk. To explain what modelling is, the EA have river models which simulate the flows and depths over a range of different storms, which can be used to aid feasibility and design of a flood risk scheme. This modelling and evidence is essential to allow DCC to consider the removal of the access bridge, as a stopping up order would also be required, under Section 116 of the Highways Act 1980. DCC remains committed to exploring opportunities for progressing this work, and will continue to liaise with the Environment Agency to identify how the necessary evidence might be compiled, if it can be demonstrated that it would reduce the flood risk. The stopping up order would also be subject to public consultation. At this stage, it’s challenging to define precise timescales for this work due to a number of uncertainties. We’re actively working to clarify these uncertainties, and will provide a more definitive timeline as soon as conditions allow. DCC is also exploring the feasibility of constructing a Flood Alleviation Scheme on the Spital Brook, which is an ordinary watercourse (rather than a main river) and would therefore fall under the remit of DCC as the Lead Local Flood Authority to consider, rather than the EA. The scheme would provide upstream attenuation in times of heavy rainfall, thereby potentially reducing the flood risk further downstream, at the point it connects into the River Rother. To date, two grant funding bids have been submitted which would fund the feasibility study of such a scheme. The outcome of these two bids is expected to be around February/March 2026. It’s worth noting that a scheme of this magnitude would take approximately 5 to 10 years to deliver and is subject to appropriate funding being made available. DCC in its capacity as Lead Local Flood Authority is wholly reliant on grant funding from government agencies, to take forward and deliver any flood mitigation schemes in Derbyshire. DCC will continue to work collaboratively with the EA, through the Derbyshire Resilience Partnership (DRP) Flood Group. This will include working closely on local engagement, encouraging residents to sign up to receive flood warnings. The DRP Flood Group will review existing flood plans and evacuation procedures for the Chesterfield area, developing these where necessary.

Derbyshire County Council 24th October 2025
Environment Agency Regulator / Inspectorate
29 Oct 2025
Noted
The Environment Agency expresses condolences and explains that while they have powers to build flood defences, they are not able to eliminate the risk of flooding entirely. They will continue to work with communities and provide a Flood Warning Service and carry out winter maintenance walkovers. (AI summary)
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Dear Mr Kewley Environment Agency Response to a Report to Prevent Future Deaths under Regulation 28, Coroners (Investigations) Regulations 2013, dated 8 September 2025, following the fatality of Maureen Gilbert at Tapton Terrace, Chesterfield On behalf of the Environment Agency, I would like to send our sincere condolences to the family of Mrs Gilbert. You reported the following matter of concern at the conclusion of the inquest, as set out in the Regulation 28 Report – “Following the flood damage to Tapton Terrace in 2007, the Environment Agency’s pre-feasibility study identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. None of these measures were implemented principally due to cost reasons. When Storm Babet hit in October 2023, Tapton Terrace remained in the same position that it was in back in 2007. Due to the ongoing lack of flood defences, Tapton Terrace remains vulnerable to flooding. I am concerned that this gives rise to a risk to life, particularly in respect of residents who may be elderly, vulnerable or immobile.” The Environment Agency’s response is as follows, setting out the details of action taken or proposed to be taken, and likely timescales. Provision of Flood Defences at Tapton Terrace The Environment Agency has powers contained in the Water Resources Act 1991 to build and deliver flood risk management schemes across England. In terms of flood risk, all flood defences constructed have a residual risk of being overtopped. Building flood defences reduces and minimises the risk of flooding to communities but defences are not able to eliminate that risk or a risk to life. The Tapton Terrace Pre-Feasibility Study from April 2008 recommended that the proposed storage areas on the River Hipper and at the Avenue were taken forward to feasibility stage or beyond. The Pre-Feasibility Study confirmed that there were no affordable options to deliver flood defences at Tapton Terrace. Based upon the existing appraisal and funding rules that must be followed, together with the huge increase in construction costs in recent years, the options remain unaffordable.

Chief Executive’s Office, Environment Agency, Seacole Block, 2 Marsham Street, London SW1P 4DF chief.executive@environment-agency.gov.uk

However, from April 2026 we anticipate that revised appraisal and funding rules will be brought into effect that might result in a different outcome at pre-feasibility stage. Therefore, we propose to undertake a further study (now referred to as Strategic Outline Case) to reassess the technically feasible, environmentally acceptable, and cost beneficial flood defence options at Tapton Terrace under the new rules when in force. The study will involve carrying out updated modelling and appraisal work. We are of course unable to predict the outcome of the study or guarantee that this will result in a feasible and affordable flood defence scheme being delivered at Tapton Terrace, however we will commence the process of undertaking the study in 2026. Whilst no flood defences were delivered at Tapton Terrace following the 2007 floods, the Avenue Flood Balancing Reservoir, 4km upstream, was delivered as a flood risk management scheme by Homes England, in partnership with the Environment Agency and brought into operation in 2018. As explained in evidence at the inquest, the reservoir operated to capacity during Storm Babet. Without this substantial storage capacity, Tapton Terrace would have flooded much earlier, with higher flows in the River Rother coinciding more closely with the peak flow from the River Hipper. We are continuing to work with flood risk partners such as Derbyshire County Council to develop other flood alleviation schemes, including further natural flood management and storage within the River Rother catchment upstream of Tapton Terrace. Such an approach is consistent with the Agency’s Catchment Flood Management Plan for Chesterfield. We are currently leading the appraisal of the River Hipper Flood Alleviation Scheme. The scheme would contribute to a further reduction in flood risk to the community at Tapton Terrace through the storage of flood waters upstream, thereby reducing peak flows. At this stage we are unable to quantify the reduction in flood risk that each project might provide to Tapton Terrace, as the modelling work for each project has yet to be started. We will take action, where indicated, in accordance with our responsibilities, but schemes would need to be feasible and affordable in order to be delivered. Channel Conveyance Improvements Improving the capacity of a river channel can help to reduce flood risk by improving channel conveyance. Improvements can include raising the height of, or removing, constraints such as bridges. Improvements can also include maintenance activities such as dredging and vegetation management. Before being carried out, the Agency would consider any downstream impacts that might arise so that flood risk is not increased downstream, as well an assessment of their overall sustainability. As you know from the evidence we presented, the Agency carried out river channel surveys in 2024 following Storm Babet in order to compare the river channel against earlier surveys carried out in 2011. The 2024 surveys demonstrated that the profile of the river channel has remained static with negligible changes over the period since 2011. Based upon this evidence, we remain of the view that dredging the river channel at Tapton Terrace would not provide any flood risk benefit to the community. If there is a more significant increase in the level of the riverbed or other significant changes in profile in the future, then the Agency would work with riparian owners to assess whether dredging works would be possible and take action where necessary. We will continue to carry out winter maintenance walkovers of the river channel at Tapton Terrace to check the need for vegetation management as part of our ongoing risk management of main river channels and take action accordingly.

Chief Executive’s Office, Environment Agency, Seacole Block, 2 Marsham Street, London SW1P 4DF chief.executive@environment-agency.gov.uk

We are working with Derbyshire County Council to support them with their investigations into the removal of the Crow Lane Bridge, which is a County Council adopted highway asset. In 2026, we will include updated modelling work as part of the study to be prepared by the County Council in order to assist their technical understanding of the flood risk benefits of removing the bridge. As noted in the Pre-Feasibility Study in 2008, removal of the bridge may provide some limited benefit to the area immediately upstream of Tapton Terrace itself. Flood Warnings and Improving Resilience As you are aware, the Environment Agency has a statutory responsibility to manage the risk of flooding from main rivers, reservoirs, estuaries, and the sea. Part of our response to these risks is the national Flood Warning Service. This provides communities and our flood risk partners with advanced warning of flooding. It is important that those at risk of flooding are signed up to our Flood Warning Service so they can act appropriately. Our Flood Warning Service includes a Flood Warning at Tapton Terrace where the circumstances arise, and currently 20 of the 26 properties at Tapton Terrace are signed up to receive that warning. After flood events we validate the accuracy of our flood warnings and make improvements where necessary. Over time we also improve our IT systems that provide the warnings and improve our flood forecasting models that predict the timing and extent of flooding. In response to the increasing challenges posed by future flood risks we have replaced our existing ‘Sign up for flood warnings’ service on GOV.UK with a more advanced, user-focused, and resilient service. The improved ‘Get flood warnings’ service continues to provide timely and accurate flood warning messages to those at risk, using modern technology to better meet the needs of the public, businesses, organisations, and emergency responders, ensuring improved accessibility, reliability, and responsiveness during flood events. The new ‘Get flood warnings’ service launched on 21 October 2025. We are an important member of the Floods Resilience Taskforce which has been set up to improve our preparedness for, and resilience to, all types of flooding affecting people, homes, and businesses. The Floods Resilience Taskforce brings together experts and decision makers from across UK Government, non-governmental bodies, and industry organisations at local and national level. It includes stakeholders that are involved in all stages of flooding resilience, including preparedness, response, and recovery. The Agency will continue to take action to improve our systems and processes in order to provide the best Flood Warning Service that we can, which includes working with communities to improve sign-up rates. We will continue to work with national experts and decision makers to improve flood resilience and to create climate resilience in line with our national flood and coastal erosion risk management strategy. Compulsory Purchase Compulsory purchase is a legal function that allows certain public bodies to acquire land or rights over land for a specific purpose, if the landowner is not willing to sell by agreement. Conceivably, the appropriate public body could seek to compulsory purchase all the properties at Tapton Terrace in order to eliminate the risk to life from flooding at this location. The purchase of the properties would be carried out through a Compulsory Purchase Order. The Environment Agency has compulsory purchase powers, but these can only be used as part of the delivery of a flood risk management scheme, for example where a flood defence needs to be built in the same location of an existing property. As there is currently no feasible flood scheme at Tapton Terrace requiring the removal of the houses, we would not be able to use our compulsory purchase powers in this instance. Therefore we are unable to take action to that extent in relation to Tapton Terrace.

Chief Executive’s Office, Environment Agency, Seacole Block, 2 Marsham Street, London SW1P 4DF chief.executive@environment-agency.gov.uk

We hope that this information addresses the concern that you have raised. Please let us know if there is anything further that you require in response to your report. We are dedicated to working with our partners and communities to strengthen resilience to flooding in response to the growing challenges posed by climate change.
Department for Environment Food Rural Affairs Central Government
3 Nov 2025
Action Planned
Defra acknowledges the concerns and highlights its national responsibility for flood risk management. The Minister will meet with representatives from Derbyshire County Council and the Environment Agency to discuss flood protection in Chesterfield ahead of winter. (AI summary)
View full response
Dear Coroner Kewley,

Thank you for your report of 8 September regarding the death of Mrs. Maureen Gilbert. I was very sorry to learn of her tragic death in October 2023, and I would like to express my sympathies to Mrs. Gilbert’s family for what has been a deeply upsetting time for them. I would also like to thank you for your thorough investigation into the details of the incident and your report.

Flooding devastates communities. We take our responsibility in reducing these risks extremely seriously and we have acted to increase investment, change the rules around how funding for flooding is allocated and set up a Flood Resilience Taskforce to improve how prepared the country is for flooding.

With respect to flooding at Tapton Terrace during Storm Babet, I view your findings with the utmost gravity. Before responding to your specific requests, it is first important for me to be clear on the roles of the parties to whom you have written.

Defra has overall national responsibility for policy on flood and coastal erosion risk management (FCERM) in England, providing funding for flood risk management through grants to the Environment Agency, local authorities and internal drainage boards. It is the Lead Government Department for all flood planning and response and activates its response systems in larger flood emergencies.

The Environment Agency is responsible for taking a strategic overview of the management of all sources of flooding and is responsible for the operational flood response to flooding from main rivers, the sea and reservoirs. It is important to emphasise that while the construction of flood defences can manage flood risks, defences are not able to entirely eliminate the risk of flooding or a risk to life. Ahead of expected flooding, with the help of the emergency services and Lead Local Flood Authorities, the Environment Agency warns and informs people at risk and puts staff on the ground to erect defences, clear blockages and coordinate other responders.

Derbyshire County Council, as the Lead Local Flood Authority for Chesterfield, is required to manage and investigate local flood risks from surface water, groundwater and ordinary watercourses, working closely with other risk management authorities, including the local highway authorities, water companies and internal drainage boards, among others. Evacuation and shelter are the responsibility of the local authority, working alongside the Environment Agency and others in a multi-agency response.

2 My department and the Environment Agency have considered the protections that were in place ahead of the flooding, the response that took place, and, in accordance with your report, considered the actions being taken and the proposed timescale for such action.

Response to Storm Babet in Chesterfield

Storm Babet in 2023 was a major flooding event. There was significant flooding across Chesterfield, with 600 properties affected. It was classified as a national flood emergency, and as the Lead Government Department, Defra stood up its Emergency Operations Centre.

Chesterfield and Tapton Terrace are located within the Upper River Rother Catchment, and the Flood Warning Service operated as it should have for this area. The Environment Agency’s Avenue Flood Balance Reservoir, 4 kilometres upstream, operated and filled to its capacity. Had the reservoir not operated to its full capacity Tapton Terrace would have flooded much earlier and with substantially higher flows. Nationally, an estimated 96,000 properties were protected by the Environment Agency during Storm Babet. It is important to state that, with the impacts of climate change, we are likely to see more events on the scale of Storm Babet in the future.

Action since Storm Babet

The Environment Agency’s response to you provides further detail on the response to the flooding in Chesterfield during Storm Babet. It also includes an articulation of the range of options that have been considered since 2023 to reduce the flood risk at Tapton Terrace.

A key issue that had been the subject of scrutiny throughout your inquest was whether there are any feasible further options for flood schemes that would directly protect Tapton Terrace. As you highlighted in your report, potential technically feasible options had been identified in a 2008 pre-feasibility study but none were found to comply with the government’s spending rules, as set by HM Treasury’s Green Book, which require all projects to demonstrate value for money in order to be considered for funding. These spending rules are key to prioritising spend across government.

Taking into account the findings from your report, the fact that 18 years have passed since the last pre-feasibility study and with the introduction of new appraisal and funding rules, I agree with the Environment Agency’s conclusion that a new pre-feasibility study (which is now referred to as a Strategic Outline Case) should be taken forward and will underline to the Environment Agency’s Chief Executive, when we next meet, that this should be undertaken in 2026. As the Environment Agency’s response sets out, if a viable option is identified, it can then be considered for funding under the new, more straightforward funding rules, which take effect in April 2026.

In addition to considering the need for a new Strategic Outline Case, the Environment Agency, as detailed in its full response, is leading the appraisal of the River Hipper Flood Alleviation Scheme, which has secured just under £400,000 funding for the next phase of development. The Environment Agency estimates that this phase (known as the Outline Business Case) should commence in spring 2026 and is understood to take a minimum of two years to complete, subject to funding. In addition to this, there is ongoing preliminary work to explore further natural flood management and storage within the River Rother catchment, upstream of Tapton Terrace. As the Environment Agency’s response to you explains, it is also supporting Derbyshire County Council with its ongoing investigations

3 into the removal of Crow Lane Bridge, upstream from Tapton Terrace on the River Rother. The 2008 pre-feasibility study indicated that the removal of this bridge would lower the river levels upstream from Tapton Terrace during flood events. In 2026, updated modelling work by the EA will be undertaken to assist the County Council’s technical understanding of the benefits in removing the bridge.

The Environment Agency’s improved ‘Get flood warnings’ service, increasing accessibility, reliability, and responsiveness during flood events, launched on 21 October 2025. Currently, records show that 20 out of the 26 properties at Tapton Terrace are registered to receive Flood Warnings.

Dredging is one further option considered by the Environment Agency. Dredging and main river clearance is an important part of the Environment Agency’s wider annual programme of channel maintenance work. Before undertaking dredging, the Environment Agency works in close consultation with local communities to assess whether it is technically achievable, cost effective, and does not significantly increase flood risk for others downstream. The response from Environment Agency explains why, on the basis of evidence from 2024, they believe dredging the river channel at Tapton Terrace would not provide any flood risk benefit to the community.

The Environment Agency will also continue to carry out winter maintenance walkovers of the river channel at Tapton Terrace and take action accordingly.

I have discussed these issues with the constituency MP for Chesterfield. In June of this year, I responded to a debate in Parliament called by Toby Perkins MP about flooding in his constituency. I also met with him last week, on 26 October, to discuss Tapton Terrace. One of the issues raised by Toby Perkins was the potential for Compulsory Purchase Orders in relation to Tapton Terrace. I suggested to him that this would be something to discuss with the local council in the first instance. I agreed to remain in touch about potential options ahead.

Moving forward from here, as Minister for Water and Flooding, I remain committed to helping increase the resilience of Tapton Terrace, Chesterfield and the whole country to flooding. Having met with Toby Perkins MP, I will also meet with Chris Henning (Executive Director at Derbyshire County Council) and Philip Duffy (Chief Executive at the Environment Agency) to discuss flood protection in Chesterfield ahead of this winter.

Thank you once again for your important inquiry and report. Please do not hesitate in contacting me if there is anything that I can clarify.
Sent To
  • Environment Agency
  • Derbyshire County Council
  • [REDACTED], Parliamentary Under-Secretary of State (Minister for Water and Flooding)
Response Status
Linked responses 3 of 3
56-Day Deadline 3 Nov 2025
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 26 October 2023 I commenced an investigation into the death of Maureen Gilbert who was 83 years old when she died on 21 October 2023. The investigation concluded at the end of the inquest on 5 September 2025. I concluded that Mrs Gilbert drowned in her own home due to flood waters caused by Storm Babet.
Circumstances of the Death
Mrs Gilbert lived her entire life on Tapton Terrace in Chesterfield. Tapton Terrace runs along the banks of the River Rother. It consists of 26 houses in total. Tapton Terrace is known to be at risk of flooding. This is due to multiple factors including the presence of two other water sources that discharge into the River Rother just upstream of Tapton Terrace (namely the River Hipper and Spittle Brook) and the absence of flood defences at Tapton Terrace.

In 2007 Tapton Terrace was badly damaged due to flooding. A pre-feasibility study commissioned by the Environment Agency in 2008 identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. However, none of these options were implemented as they were not considered to be cost effective.

In 2018 the Avenue Flood Balance Reservoir became operational further upstream on the River Rother. This is a large water storage area on the River Rother which is designed to hold back water upstream with the aim of reducing water flow downstream.

Also in 2018 Mrs Gilbert’s house was fitted with a number of property flood reduction measures such as front and rear door flood barriers to help protect against water ingress. These measures, however, only provided protection up to a water level height of 0.6m.

On 20 October 2023 the River Rother burst its banks at Tapton Terrace. This was caused by significant levels of rainfall during Storm Babet. The river levels reached a record level. Despite the best efforts of the emergency services on 20 October 2023 Mrs Gilbert could not be rescued from her house on Tapton Terrace.

On 21 October 2023 Mrs Gilbert was found deceased in her lounge. She had drowned as a result of the flood waters entering her property on Tapton Terrace.
Copies Sent To
Parliamentary Under Secretary of State (Minister for Water and Flooding) , Executive Director at Derbyshire County Council , Chief Executive of the Environment Agency following individuals who may find it of interest Derbyshire Fire and Rescue , Chesterfield Borough Council , MP for Chesterfield

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.