Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0053, written 6 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2014 |
|---|---|
| Reference | 2014-0053 |
| Deceased | Brian Kent |
| Coroner | Dr R N Palmer |
| Coroner area | South London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
,. H.M. Senior Coroner, South London Area South London Coroner's Office Saint Blaise Building, Bromley Civic Centre Stockwell Close, Bromley BR1 3HU Telephone 020-8313 1883 Fax 020-8313 3673 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: His Excellency the Ambassador for Italy 1 | CORONER | am the senior coroner for the coroner area of South London 2 | CORONER’S LEGAL POWERS | 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 29" May 2013 | commenced an investigation into the death of Brian Robert Henry KENT aged 45 years. The investigation concluded at the end of the inquest on 23° January 2014. The conclusion of the inquest was as recorded on the Record of Inquest, a copy of which is enclosed. 4 | CIRCUMSTANCES OF THE DEATH Please see enclosed letter to His Excellency the Ambassador 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 set out in the enclosed letter and enclosures 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you may be able to ensure that such action is taken. 1 Coroner's Court, Barclay Road, Croydon, CR9 3NE Telephone 020 8681 5019 Facsimile 020 8686 3491 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5" May 2014. |, 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 | have sent a copy of my report to the Chief Coroner and to the Mr Kent's family. | 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 | 6" February 2014 Dr R N Palmer le HM Senior Coroner 2 Coroner's Court, Barclay Road, Croydon, CR9 3NE Telephone 020 8681 5019 Facsimile 020 8686 3491 Her Majesty's Coroner Southern District of Greater London Coroner's Office St Blaise Building, Bromley Civic Centre, Stockwell Close, Bromley BR1 3UH Telephone 020 8313 1883 Facsimilie 020 8313 3673 5" February 2014 Our ref: HMSC/LIT/01333/2013/RY/TS His Excellency Ambassador Pasquale Terracciano The Italian Embassy in London 14 Three Kings Yard LONDON W1 1EH Dear Ambassador Inquest Touching the Death of Brian Robert Henry KENT Born: 08 June 1967 Died: Sperlonga Beach, Italy 17 May 2013 Prevention of Future Deaths Report I write pursuant to paragraph 7 (1) of Schedule 5 of the Coroners’ and Justice Act 2009, and pursuant to the Coroners’ (Investigations) Regulations 2013, Regulation 28. | am required as Coroner to make such a Report where | hear, at an inquest, evidence that leads me to believe that if action is not taken, other people will be at risk of dying in similar circumstances. Brian Kent and family members were on holiday in Rome and on 13 May 2013, went on a day trip to Sperlonga beach. Brian Kent went into the water with family members and became submerged. He died at the scene and the cause of his death was established as drowning. In the course of my investigations | received a report from the Public Prosecutor’s Office Latina, a copy of which | enclose. | also enclose the translation which we had made. The report indicates that at all material times, a lifeguard service should have been provided on that beach. | heard evidence from family members that there was no such lifeguard present on the day in question. | write this report in the hope that you can ensure that steps are taken to rectify the situation and to arrange for a lifeguard service always to be provided. Additionally, perhaps some consideration can be given to putting up warning signs for those intending to bathe. Coroner's Court, Barclay Road, Croydon CR9 3NE Telephone 020 8681 5019 Facsimilie 020 8686 3491 As well as this letter | also enclose the statutory form which | am obliged to send to you and a copy of which will be sent to the office of the Chief Coroner for England and Wales. Yours my DrRN PALMER H M Senior Coroner South London Area Enc
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