Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0424, written 2 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Oct 2014 |
|---|---|
| Reference | 2014-0424 |
| Deceased | Gavin Bradley, Mark Thorpe and Darren Thorpe |
| Coroner | Eric Armstrong |
| Coroner area | Northumberland (South) |
| Category | Other 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. Kevin Morrell, Head of Business Continuity, Northumbria Water
2.
3.
CORONER
1
I am Eric Armstrong, senior coroner, for the coroner area of Northumberland (South)
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 15th May 2014 I commenced an investigation into the death of Darren William Thorpe
Age 41: Gavin Thomas Bradley Age 36: and Mark Thorpe Age 39. The investigation
concluded at the end of the inquest on 25th September 2014. The conclusion of the
inquest was That each died of drowning and each was an Accidental Death.
4
CIRCUMSTANCES OF THE DEATH
On the morning of the 11th May 2014 the three men entered the river Tyne on a “sit on “
Kayak, in the Hexham area. An alarm was raised by a family member when the men
failed to return or to contact any of their families. A Police search, assisted by an RAF
helicopter and other organisations located the bodies of all three men at points
downstream of the Riding Mill weir. One Kayak was located at the weir and other items
were recovered downstream of the weir.
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) Evidence was given that in other countries within Europe, weirs are constructed
with a specific channel to allow the passage of canoes and kayaks without
encountering the tow back, or stopper, caused by the anti-scour sill at the foot of
the weir. Would it be feasible to amend the design of the Riding Mill weir to
incorporate such a channel?
(2) Evidence was given that on a previous visit to the River Tyne the men had
exercised due caution in negotiating the weir by alighting upriver of the weir. It
was felt that the most likely interpretation of the known circumstances was that
the kayakers had been unable to exit the river because of the flow of water.
Would it be feasible to construct a suitable landing area, accompanied by
1
appropriately worded warnings, sufficiently far upriver to enable an exit from the
river even at the time of a heavy flow of water?
(3) Are there any other steps which might be taken to avoid a repetition of the
circumstances surrounding these three deaths?
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation 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 November 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
.
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
2nd October 2014
2
See every Prevention of Future Deaths report matching Eric Armstrong, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.