Sally Blundell, 58, died after the hydraulic coffin lifter she was using descended unexpectedly at East of England Co-op Funeral Services in Swaffham.

Norfolk area coroner Yvonne Blake said she would be issuing a prevention of future death report to the manufactures of the trolly A R Twigg & Son.

Before they retired to consider the evidence, she told jurors they must decide when, where and how Mrs Blundell met her death, stressing: “This is not a trial - it is an inquest to find out how Sally died.”

A forensic services van outside the East of England Co-op Funeral Services in Swaffham (Image: Christopher Bishop)

After deliberations, the jury concluded that while working alone as a funeral arranger she suffered fatal chest compression when she became positioned within the mechanism of the trolley, which then descended without warning.

Mrs Blundell, who lived on The Street in Great Cressingham, died on December 1, 2023.

Her daughter Lucy Blundell was in court for the final day of the hearing.

The inquest heard how the experienced funeral professional had returned to work at the Swaffham branch in July 2022 after previously working for the company.

Area coroner Yvonne Blake accepted the jury's conclusion that Mrs Blundell's death was an accident (Image: Newsquest/East of England Co-op)

Mark Ling, East of England Co-op cluster manager responsible for 15 funeral branches, described her as “a stickler for the rules” who was conscientious and always willing to seek guidance.

“She was very experienced and a good arranger,” he said. “She would email or call with any concerns and was happy to ask for assistance. I was satisfied she was competent to operate the trolley.”

Health and safety evidence was given by risk and assurance officer Neil Renaut Cmiosh, who told the court the organisation employed around 3,000 people across 49 branches in Norfolk, Suffolk and Essex.

He said colleagues received manual handling training and one-to-one instruction in using the coffin lifter, which was designed to be straightforward to operate for one person.

The trolley involved in Mrs Blundell’s death had been purchased new in 2018 from supplier of mortuary equipment A R Twigg & Son and had been subject to annual inspections and servicing. No defects had been formally reported in the years leading up to the incident.

However, all expert witnesses agreed a fault later found in the mechanism had caused the trolley to descend unexpectedly.

Evidence showed the spring coil within the hydraulic system had likely stretched, preventing the valve from closing fully and allowing the platform to lower without warning.

An estimate 1500 trollies of the same design are still in use (Image: Norfolk Coroner's Court)

The inquest also heard the model was widely used across the funeral industry, with an estimated 1,500 still in operation nationally.

Following Mrs Blundell’s death, all 14 trolleys of the same type used by the East of England Co-op were withdrawn from service and replaced with electrically operated lifting systems.

A post mortem found she died from compression of the chest caused by an external force. Toxicology tests showed no evidence of drugs or alcohol.

Speaking on behalf of the family after the hearing, Lucy Blundell issued a statement through solicitor Michael Wangermann, thanking the coroner and all those involved in the investigation.

“We want to express our thanks to the coroner, Breckland Council and everyone who has contributed to the inquest process,” she said.

“We are pleased that a conclusion has now been reached and welcome news that the coroner will be taking further steps to prevent a tragedy like this happening again."

The jury recorded Mrs Blundell's death was an accident and that she died from chest compression after the mortuary trolley descended unexpectedly while she was working alone.

Timeline of Sally Blundell’s final hours

9.00am — Mrs Blundell seen speaking with members of the public at the Swaffham funeral branch.

9.01am to 9.46am — CCTV shows her working at her desk.

9.46am — She is seen entering the chapel of rest area which leads to the preparatory room.

10.59am — Two clients arrive for a scheduled appointment and briefly enter the chapel after finding reception unattended.

11.15am — Colleague Steven Kemp receives a call alerting him that clients are waiting at the branch.

11.59am — Mr Kemp arrives at the premises and enters the chapel of rest and proceeds to the prep room,

12.04pm — Emergency services are called after Mrs Blundell is found beneath the mortuary trolley.

12.07pm — Her husband arrives at the branch.

12.11pm — Police officers arrive.

12.13pm — Paramedics attend the scene, and she is later declared deceased.

© Eastern Daily Press