Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0093, written 3 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2014 |
|---|---|
| Reference | 2014-0093 |
| Deceased | Marco Lima De Araujo |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A 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: Commander N. Hare, Queen's Harbour Master, Portsmouth 1 CORONER I am David Clark Horsley, senior coroner, for the coroner area of Portsmouth and South East Hampshire 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 20th August 2012 I commenced an investigation into the death of Marco Antonio Lima De Araujo The investigation concluded at the end of the inquest on 13th February 2014. The conclusion of the inquest was: The aforementioned person died due to an accident. The medical cause of his death was drowning. 4 CIRCUMSTANCES OF THE DEATH On 8th August 2012 the body of Marco Antonio Lima De Araujo was recovered from the water in Portsmouth Dockyard. On 26th July 2012 at about 15.45 hours he had gone into the sea by the Round Tower, Portsmouth, to assist in the rescue of two children who had got into difficulties in the sea. He was not seen alive again. 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. – I was told at the Inquest hearing that there is no formal protocol for reporting and co- ordinating rescue in relation to life threatening incidents in Portsmouth Harbour. 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 28th April 2014. I, the coroner, may extend the period. 1 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 [NAMES] [and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to [NAMED PERSON] who may find it useful or of interest. 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 3rd March 2014 David Clark Horsley 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Maritime Operations Bay 2/07 Re Spring Place q 105 Commercial Road is _ Southampton RECEIVED Maritime & S015 1EG 17 APR 2014 Coastguard BY H.M CORONER Agency To: David C. Horsley rel The Coroner’s Office E-mait: The Guildhall Guildhall Square ; Your ref: Report 3 Mar 14 De Portsmouth Araujo PO1 2AB 15 April 2014 Dear Sir, This letter is in response to the Regulation 28 matter of concern outlined in your report “that there is no formal protocol for reporting and coordinating rescue in relation to life threatening incidents in Portsmouth Harbour”. Her Majesty’s Coastguard is responsible for the initiation and coordination of civil maritime search and rescue within the United Kingdom search and rescue region. This includes the mobilisation, organisation and tasking of adequate resources to respond to persons either in distress at sea, or to persons at risk of injury or death on the cliffs or shoreline of the United Kingdom. (Secretary of State for Transport, House of Commons, 9 March 1992). The formal protocols, for persons on land, for the alerting of HM Coastguard are by calling 999 and ask for coastguard. Persons or vessels at sea use the global maritime distress and safety systems (GMDSS) protocols. Her Majesty’s Coastguard have long standing arrangements with the Queen’s Harbour Master, Portsmouth (QHM) (and all Harbour Authorities) that allow for mutual communication and cooperation during search and rescue activities within harbour limits. Both organisations have direct dial telephone lines between each other and can also communicate on marine band radio frequencies within the GMDSS. When a Maritime Rescue Coordination Centre (MRCC) of HM Coastguard is alerted to an incident within harbour limits they will task and coordinate appropriate search and rescue units to resolve the incident, at the same time they will communicate with QHM and often request resources to assist. Where the QHM is made aware of an incident they will alert HM Coastguard and frequently task their own resources and hand coordination to the MRCC. The appropriate MRCC in the case of QHM Portsmouth is MRCC Solent. & gS, INVESTORS SEA ai @ 4,’ IN PEOPLE ‘G) VISION HM Coastguard MRCC Solent and QHM are members of the SOLFIRE multi-agency response group encompassing all harbour, emergency and local authorities that would respond to major incidents in the Solent. These organisations take part in annual multiagency exercises. | hope that this answers the matter of concern in your report. For Chief Coastguard Maritime Operations HM Coastguard Copy to: — “ Portsmouth ] SEA NE) UKAS 4, 2h IN PEOPLE i” Sy INVESTORS ©) 4 | SEA
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