Overview
- Mrs Beryl Barrett’s leading walking‑frame wheel became trapped on December 19, leaving her with a fractured hip and leading to her death from bronchopneumonia on December 25, a coroner ruled accidental and said the fall more than minimally contributed to her death.
- The surface defect that caused the fall was later measured at under 20mm and so did not meet the national ‘actionable’ repair threshold for pedestrian crossings.
- Video from a December 1 inspection shows an inspector applied a 40mm carriageway threshold instead of the 20mm crossing threshold, which meant a separate defect was not flagged for repair during routine monthly checks.
- The coroner highlighted two system failures — no process to triage reports suspected of causing injury, and no national guidance for users of small‑wheeled mobility aids — noting the suspected pothole was only temporarily filled on January 2 after a 12‑day gap.
- A Prevention of Future Deaths report will be sent to Nottinghamshire County Council, Via East Midlands and the UK Roads Liaison Group to seek changes to local inspection triage and national repair guidance that could affect vulnerable pedestrians.