Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0029, written 22 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jan 2014 |
|---|---|
| Reference | 2014-0029 |
| Deceased | Paul Rogerson |
| Coroner | William Coverdale |
| Coroner area | York |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. City of York Council
2. North Yorkshire Police
3. North Yorkshire Fire and Rescue Service
1
CORONER
I am William Donald Forbes Coverdale Senior Coroner for the Coroner area of York.
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 28.03.2011 I commenced an investigation into the death of Paul Alan Rogerson
aged 26. The investigation concluded at the end of the inquest on 18.10.2011. The
conclusion of the inquest was that the cause of Mr Rogerson’s death was Drowning and
I recorded a verdict of Accidental Death.
4
CIRCUMSTANCES OF THE DEATH
On 26.03.2011 Mr Rogerson was out in York for a night out and had consumed several
pints of beer. He jumped up on to a wall on Ouse Bridge at Kings Staith and attempted
to walk along the wall but lost his footing and fell into the River Ouse. Police Officers and
passers-by at the scene threw buoys on ropes into the water but he struggled to stay
above the water and after several minutes he became submerged and did not resurface.
His body was recovered by a police underwater search unit close to the point of entry
several hours later.
5
CORONER’S CONCERNS
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. –
(1) The position and protection of life buoys and throwing lines is inadequate. Buoys are
not securely placed on the river bank and at least one was found discarded some 20
metres from the river bank. Some throwing lines are frayed, discarded and of insufficient
length to reach far across the river. The integrity of this equipment is insufficiently
protected from vandalism and the weather.
(2) There are no warning signs in place along the river bank within the city walls in York.
Only one was found in the course of my enquiry, this being attached to a life buoy
harness and being smaller than an A4 piece of paper. Public Houses near the river are
not encouraged to display prominent warning signs in areas that their customers have
access to the water.
1
(3) North Yorkshire Police Officers may require further training in current protocols for
River Rescue and Water Safety.
(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The
Fire and Rescue Service need to receive detailed information from Police Control;
mutual assistance can be given during rescues; there may be a lack of sufficient
communication from the Police on these occasions and a need for the Police to
familiarise themselves with current Fire and Rescue methods of water rescue.
(5) North Yorkshire Police officers receive first aid training in CPR and wounds but
Hypothermia is currently not covered.
(6) There are insufficient checks upon the condition of life buoys. It is understood that
City of York Council have officers who conduct periodic checks; North Yorkshire Police
Officers and Community Support Officers conduct foot patrols. There appears to be no
protocol for routine dealing with a buoy and line which are untidy or in disarray. There is
no system of reporting a missing buoy. North Yorkshire Police may need to revisit
procedures to take robust action in the event of deliberate damage or theft.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19.03.2014. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: North Yorkshire Police; City of York Council; North Yorkshire Fire and Rescue
Service. I am also sending a copy to
I am also under a duty to send the Chief Coroner a copy of your response.
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 by the Chief Coroner.
9
Dated 22.01.2014 WDF COVERDALE
SENIOR CORONER, COUNTY OF YORK
2
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