Susan Samson

I am Rebecca Sutton, senior coroner/area coroner/assistant coroner, for the coroner area of County Durham and Darlington.

On 08 May 2025 an investigation into the death of Susan Elizabeth SAMSON aged 78  was commenced. The investigation concluded at the end of the inquest on 12 February 2026. The conclusion of the inquest was that: On 7 May 2025 at her home address in  Darlington, the deceased died due to an accidental fall down the stairs. The death was  caused by an accident, which was contributed to by an unsafe discharge home from a  rehabilitation placement.

The deceased had a recent history of falls and had been admitted to hospital on 27  February 2025.  She was using a wheeled walking frame to mobilise and experienced  difficulty when attempting to use stairs. It was identified on 12 March 2025 that the  deceased would benefit from a second banister rail on her discharge from hospital. There was an attempt to discharge the deceased home on 19 March 2025, which was  unsuccessful, as her legs were buckling on the stairs. It was decided that it was not safe for the deceased to stay at home and she was admitted to Rydal Care Home for a six- week period of rehabilitation. Between 19 March 2025 and 1 May 2025 there were  numerous attempts to assess whether the deceased was safe to use stairs without  assistance. The first time that the deceased managed to successfully complete the stairs without requiring prompting was on 28 April 2025. There was a second successful attempt on the stairs on 30 April 2025.  The deceased was discharged home on 1 May  2025 (at the end of the six-week rehabilitation period).  An Occupational Therapist  accompanied the deceased home and observed the deceased using her own staircase.  By that time the second banister rail had not been installed.  The Occupational Therapist deemed the deceased to be safe using her stairs. On 7 May 2025 the deceased fell down her stairs and died due to the injuries sustained in that fall.

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

1. On 18 March 2025 (via an email timed at 16:19) a request was made by staff at Sedgefield Community Hospital to Darlington Borough Council (who were the  landlord of the property where the deceased lived) to fit a second banister rail in the deceased’s home.
2. On 10 April 2025 a further request, by an Occupational Therapist working at the Rydal Care Home, was made to Darlington Borough Council to fit a second  banister rail in the deceased’s home.
3. An appointment was made to fit the second banister in the deceased’s home on 6 May 2025.
4. For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025.

I am concerned by the length of time between the requests for a second banister and the first appointment arranged to fit a second banister. I am concerned that, if similar circumstances arose today, or in the future, a Darlington Borough Council tenant could be exposed to a potentially avoidable risk of death while awaiting the installation of a second banister.

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