Elizabeth Bury

I am Emma Serrano, Assistant Coroner, for the coroner area of Staffordshire

On the 12 April 2024, I commenced an investigation into the death of Mrs Elizabeth Margaret Bury.   The investigation concluded at the end of the inquest on 13 August 2024.  The  conclusion  of  the  inquest  was  a  narrative  conclusion  comprising  of “complications following a fall.” The cause of death was: 1a Bilateral haemothorax due to rib fractures and cardiac laceration 1b Fall 1c II Ischaemic heart disease

i) Mrs Bury was walking back to her care in Tape Street Carpark in Cheadle on the 15 February 2024.  She fell on a speed bump in the car park.  This caused bilateral haemothorax due to rib fractures and cardiac laceration. She passed away at the carpark.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. That this carpark has been the source of many falls because of the speed bumps.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.