Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0096, written 4 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 | 4 Mar 2014 |
|---|---|
| Reference | 2014-0096 |
| Deceased | Ryan Pettengell |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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.
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:
Head of Legal
Sibelco UK Ltd '
Brookside Hall
Congleton Road
Sandbach
Cheshire
WF11 4TF
Borough Council of King’s Lynn
King’s Court
Chapel Street
King’s Lynn
PE30 1EX
Principal Planner
Monitoring and Contro! (Planning Services)
Public Protection
Environment, Transport and Development
Norfolk County Council
County Hall
Martineau Lane
Norwich
NR1 2SG
Temporary Superintenden {i
Norfolk Police
The Police Station
St James Street
King’s Lynn
PE30 1ES
1 | CORONER
| am JACQUELINE LAKE, Senior Coroner, for the Coroner Area of
_| NORFOLK
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.
INVESTIGATION and INQUEST
On 22 July 2013 | commenced an investigation into the death of RYAN
JAMES PETTENGELL, then aged 41 years. The investigation concluded
at the end of the inquest on 25 February 2014. The conclusion of the
inquest was Accidental Death, the medical cause of death being
Drowning.
CIRCUMSTANCES OF THE DEATH
(1) On 16 July 2013 Mr Pettengell went with friends to a disused
quarry at Bawsey, King’s Lynn.
(2) The quarry is a popular recreation area which includes various
lakes.
(3) There is an Agreement in place that the area will be accessible to
the public for recreational purposes. Swimming in the lakes is
prohibited.
(4) Mr Pettengell entered one of the lakes and attempted to swim to a
nearby island.
(5) Mr Pettengell got into trouble and drowned.
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 site has been officially closed since this incident (and another
drowning on the same day) whilst meetings are ongoing with the
community as to the best way to provide recreational facilities to the
public whilst having regard to the public’s safety;
(2) Recommendations were put forward by the King’s Lynn and West
Norfolk Council on 20 August 2013 with regard to increasing safety at the
site;
(3) Six months later, no action has been taken with regard to increasing
safety at the site.
(4) Evidence was given at the inquest that the public are still gaining
access to the site;
(5)There is no signage around the lake prohibiting swimming in the area
where Mr Pettengell entered the water;
(6) Some of the existing signage is damaged and/or has been removed.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and |
believe your organisation has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date.
of this report, namely by 30 April 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following
Interested Persohs:-
West Norfolk and King’s Lynn Borough Council and Sibelco UK Ltd.
| have also sent it to Norfolk County Council and Norfolk Constabulary
who may find it useful or of interest.
Derek Winter (Archivist)
HM Coroner for the City of Sunderland
Civic Centre
Burdon Road
Sunderland
SR2 7DN
(mother)
lam 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.
4 March 2014 CJ [SIGNED BY CORONER]
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