Mr Peter John Moorby · Prevention of Future Deaths report

On 10 September 2021, an investigation was commenced into the death of Mr Peter John MOORBY (“Peter”). Peter’s inquest was opened on 22 September 2021 and concluded on 8 February 2022.

The medical cause of Peter’s death was:

1a Head Injuries

The determination was:

Mr Peter John Moorby died at the Royal Lancaster Infirmary on 5 September 2021. Mr Moorby had been seen to leave a friend's house at about 22:30 on 4 September 2021. At approximately 01:00 on 5 September 2021, Mr Moorby was located in a beck off Millstream Court, Cark-in-Cartmel, with a severe head injury. His entry into the water was unwitnessed. Mr Moorby was found at the bottom of an 8-10 foot drop having fallen over a knee high wall in an unlit area. Mr Moorby was treated at the scene and during transfer to the Royal Lancaster Infirmary. Treatment continued there but Mr Moorby died at 05:50. Post-mortem blood evidence alcohol████████

The conclusion of the inquest was:

Accidental Death.

On the evening of 4-5 September 2021, Peter had been visiting a friend's house on ████████. When he left his friend’s house, Peter was well although under the influence of alcohol.

On 5 September 2021 at approximately 01:00, residents of ████████ heard someone in distress. Mr Moorby was found in the beck which is on the opposite side of a low wall that runs alongside the access road to ████████.

Peter had a severe head injury and was partly in the water.

Peter’s entry into the beck was over the low wall which is less than knee height. Peter had fallen approximately 8 – 10 feet into the beck.

Evidence was heard from a number of emergency services personnel about the difficulties in extracting Peter from the location.

Peter subsequently died from the injuries sustained in the fall.

Evidence was given at the inquest that there is danger during the hours of darkness as the area is unlit, the wall is so low and there are no barriers to prevent anyone falling.

I am concerned about the risk of future deaths posed by the low wall. The wall is less than knee height and offers no real protection from the significant drop of 8-10 feet into the River Eea which has a rock-strewn riverbed. The area is also unlit at night.