UK Inquiry Tracker

Lucia Stear

PFD Report All Responded Ref: 2019-0296

Date of Report 13 September 2019

Coroner Andre Rebello

Coroner Area Liverpool and Wirral

Response Deadline ✓ from report 8 November 2019

Child Death (from 2015) Other related deaths

Judiciary.uk Report PDF

All 2 responses received · Deadline: 8 Nov 2019

Coroner's Concerns (AI summary)

Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: Before the inquest Wirral MBC put in place a “Tree Action Plan”i which is address the concerns that had been before the court – This is included as an example of what can be achieved when this problem was highlighted by the death of a 15 hour old resident of the Borough. How many other public authorities are in a similar plight, not having had a fatal tragic event to prompt action? The Court asks the Rt. Hon. Secretary of State to address this issue nationally and that he advises the Court as to what steps he has directed to be taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death. The Court requests that the LGA brings this matter to the attention of its Local Authority members and that the LGA advises the court as to what steps the organisation has taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death

Responses

Local Government Association Other

30 Oct 2019

Action Planned
The LGA will include an item in its email bulletins to local authority chief executives and environmental officers, will host an online event with relevant officers by the end of December 2019, and will liaise with the Ministry of Housing, Communities and Local Government to address recommendations nationally. (AI summary)

View full response

Dear M, QZekell Re: Regulation 28 Report into the death of Lucia Jayne Stear Thank you for your Regulation 28 Report following the untimely death of Lucia Jayne Stear: Your recommendation to the Local Government Association required us to the matter to the attention of local authority members and advise the court on the steps taken to ensure that there is national learning from this tragic death: An item has been included in my weekly email bulletin to all local authority chief executives. The item will be repeated in the next issue of the LGA's email bulletin on environmental issues, due in early November: To raise and discuss the findings of your review directly with local authorities the LGA will set up an event with relevant officers by the end of December 2019, onlinelwebinar technology to ensure that it is available to a wide range of locations_ The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm: We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members_ We will also Iiaise with the Ministry of Housing, Communities and Local Government to address recommendations in your report to raise the issue nationally_ hope this gives you a clear picture of the LGA's response to your recommendation. If you require any further information please let me know

Ministry of Housing Communities Local Government Central Government

31 Oct 2019

Noted
The Ministry acknowledges the coroner's concerns and highlights the increase in Core Spending Power for local government and the allocation of funds for park renovations, noting that spending on parks is a matter for local authorities. (AI summary)

View full response

Rt Hon Robert Jenrick MP Secretary of State for Housing, Communities and Local Government Ministry of Housing; Communities & Ministry of Housing, Communities & Local Local Government Government 4th Floor Fry Building 2 Marsham Street Andre Rebello London SWIP 4DF Senior Coroner for Liverpool and Wirral HM Coroners Court Tel: 0303 444 3450 Gerard Majella Court Email: Boundary Street Liverpool WWW:gov.uklmhclg Merseyside Our Ref: 4484514 L5 2QD Your ref: 03605-2016 31 October 2019 Deo ' Ando Regulation 28 Report (re. death of Lucia Jayne Stear) Thank you for sending me copy of your Regulation 28 Report to prevent Future Deaths regarding the death of Lucia Jayne Stear as the result of the branch of a tree in Arrowe Park falling on the moving car in which she was travelling: am very sorry to hear about this tragic loss of life and would like to take this opportunity to on my deepest condolences to her family: You have asked for action to be taken nationally, to such an accident happening again: Spending on parks is a matter for local authorities: We acknowledge that local authorities are working under financial pressure , thats why this year the Chancellor has announced the biggest year-on-year real terms increase in spending power for local government in almost a decade. Core Spending Power (CSP) is expected to rise from E46.2 billion to €49.1 billion in 2020-21, an estimated 4.3% real terms increase_ This positive announcement brings a significant level of support to Iocal authorities, but we also understand the pressures that are under in particular areas such as parks and green spaces In order to provide additional assistance my Department announced in February a total of E9.7 million to be allocated directly to all local authorities across England with the expectation the award be used to undertake remedial work renovation of existing parks to enhance the green space available to their local communities. This funding enabled local authorities to target funds to those parks in their local area in need of greatest repair and improvement Wirral Metropolitan Borough Council was allocated a total of E56,295. Thank you once more for sharing your concerns would like to reiterate condolences and would be grateful if you could convey my sympathy to Lucia's family. Received 0lhev, 1 1 NOv 2019 RT HON ROBERT JENRICK MP HM Coroner pass stop they and my

Sent To

Department of Housing, Communities & Local Government
Local Government Association

Response Status

Linked responses 2 of 2

56-Day Deadline 8 Nov 2019

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

This report is about an infant baby girl, Lucia Jayne Stear who died at 15 hours old. Lucia’s mother, had been driving her car outside Arrowe Park on the 10.11.2016 at approximately 7.45 when a bough (large branch) from a large Horse Chestnut tree in Arrowe Park, fell on her moving vehicle and broke the windscreen; landing on her abdomen. Mrs Stear had to be extricated from the vehicle and paramedics attended. There was communication with the University Hospital Aintree (the regional major trauma centre) and information was exchanged, including information concerning pregnancy. was taken to Aintree Hospital. Baby Lucia was delivered by emergency C -section at 10:01 hours. She was stabilised at Aintree Hospital and was transferred to the Liverpool Women’s Hospital for ongoing care. Her blood tests showed evidence of multi organ failure. The decision was made to withdraw her treatment and she sadly passed away on 11th November 2016 at 01:11. She died from 1a Multi Organ Failure 1b Antepartum Asphyxia 1c Abdominal trauma with right broad ligament haematoma, sustained in road traffic accident (Maternal condition) During the course of five days of evidence the court heard that following restructuring and staff reductions in the last decade. The regular inspection, condition survey and tree maintenance work on parks and countryside trees in the Wirral was affected. The Court recognised that in spite of austerity statutory services still functioned, however some statutory duties suffered. Expert evidence was given that there needs to be a strategic management of tree policy, with a written policy system to ensure all trees are checked. There also needs to be effective staff training. The purpose of the policy is to detect trees before they fail, so as to keep the public safe, having regard to the location and occupancy of each tree.

Action Should Be Taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 08 November 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Lucia’s family North West Ambulance Service University of Aintree Major Trauma Centre Liverpool Women’s Hospital Wirral Metropolitan Borough Council The Health And Safety Executive and to the Local Safeguarding Board (where the deceased was 18). I have also sent it to , Barrell Tree Consultancy – Tree Expert Witness who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 13 September 2019