Freda Odette Mason · Prevention of Future Deaths report

On I commenced an investigation into the death of Freda Odette Mason aged 67. The investigation concluded at the end of the inquest on the 9th April 2019. The conclusion of the inquest was that Freda Mason died an Accidental Death.

Freda Odette Mason suffered from a number of underlying conditions including chronic obstructive pulmonary disease and osteoporosis, and had sustained a number of frailty fractures including fractures to her left humerus and to her vertebrae in 2017. On the 26th July 2018 at approximately 1145hrs, while sitting at a bus stop at the junction of Burnley Road and Victoria Street Padiham, she fell through the back of the bus shelter where a panel of glass was missing [and, on the evidence, had been missing for approximately three months]. She was admitted to Royal Blackburn Hospital at approximately 2325hrs that same day where she was found to have sustained multiple rib fractures. Surgical intervention and invasive ventilation could not be provided, due to her underlying conditions, and her respiratory function was severely compromised. She died in hospital on the 29th July 2018 at approximately 1945hrs.

LCC has a duty to maintain bus shelters within its area, and does so using a process whereby complaints are made to LCC by third parties – members of the public, councillors, employees of LCC and of bus companies – and LCC assesses the complaint and responds, effecting repairs where necessary. This is best described as a reactive process; and LCC does not operate an inspection system where it views the bus shelters. This means that unless a third party notifies LCC of a problem, it has no knowledge of it and cannot respond/repair.
In my opinion a more pro-active system of anticipating necessary repairs could prevent future deaths; and LCC has the power to take further additional steps to ensure that problems requiring repair are brought to its attention immediately – whether by implementing a regime of inspection or by ensuring that those who use/visit the shelters [including bus drivers and inspectors] are required [or encouraged, where LCC does not have the authority to require it] to notify LCC of any problem which needs attention.