Dorothy Gamby: Prevention of Future Deaths Report

Chief Executive Officer  
Office for Product Safety and Standards
Cannon House  
18 The Priory  
Birmingham  
B4 6BS 

I am:
Melanie Sarah Lee 
Assistant Coroner  
Inner North London 
Poplar Coroner’s Court
127 Poplar High Street 
London E14 0AE 

I make this report under the Coroners and Justice Act 2009,  paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 

On 2 May 2025 an investigation into the death of Dorothy Gamby age 100 years. The investigation concluded at the end of the inquest on 8 May 2025. The medical cause of death was 1a. pneumonia 1b.  fractured neck of femur (operated 22 April 2025). I made a  determination at inquest of accident. 

Dorothy Gamby was 100 years old. On 22 April 2025 she suffered a fall at home when she stood on the wide claw shaped rubber ferrule that  she had attached to the bottom of her foldable walking stick. This  caused the stick to pull apart and the collapsible mechanism to activate  when she pulled the stick up (the bottom section of the stick being held  down by her foot on the ferrule). When she fell, she sustained fractures  to her right hip and right wrist, and a small subarachnoid haemorrhage.  On 22 April she underwent surgery for her hip fracture. Post-operatively she developed progressive hypoxia and Type 2 respiratory failure,  secondary to known COPD. A chest xray on 25 April showed  pneumonia which was treated with antibiotics. Despite this she  continued to deteriorate, and given her frailty and co-morbidities, her  care switched to palliative care and she died at the Whittington Hospital on 30 April 2025.  

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.

Wide and clawed ferrules for walking sticks are widely available. They are described as providing stability, support, improved safety, ease of movement, etc. I am concerned that there is no warning that they may pose a risk if stood on or trapped when used on folding/collapsible walking sticks.  

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

You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 July 2025. I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the following.

Mrs Gamby’s daughter, [REDACTED]
HHJ Alexia Durran, the Chief Coroner of England & Wales

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it useful or of interest.  
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he  believes  may  find  it  useful  or  of  interest.  You  may  make representations to me, the coroner, at the time of your response, about the release or the publication of your response.