Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0483, written 4 Nov 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 Nov 2014 |
|---|---|
| Reference | 2014-0483 |
| Deceased | Rebecca Curtis-Small |
| Coroner | John Tomalin |
| Coroner area | Exeter & Greater Devon |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
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:
This Report needs to go to the Chief Coroner and the owner of Croyde beach. The
owners of the beach, Parkdeane Holidays — Ruda Holiday Park Ltd., Croyde Bay, North
Devon, EX33 1NP. North Devon District Council, Civic Centre, North Walk, Barnstaple,
Devon, EX31 1EA. Support Officer, Maritime and Coastguard
Agency, Bay 3/20, Spring Place, 105 Commercial Road, Southampton, SO15 1EG.
Royal National Lifeboat Institute, West Quay Road, Poole, Dorset, BH15 1HZ.
{ | CORONER
lam Mr John Geoffrey Tomalin, Deputy Coroner for the Exeter and Greater Devon Area.
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 THE 31" December 2013 | commenced an investigation into the death of Rebecca
Jodie CURTIS-SMALL, aged 42. The investigation concluded with an inquest held on 9"
October 2014. The conclusion of the inquest was Accident Death - On the 31st
December 2013 the Deceased was in the water with her family at Croyde Bay, North
Devon, when she found herself in difficulties due to sea conditions and a rip tide. After a
search involving Lifeboats, Coastguards and Royal Air Force Search and Rescue
Helicopter lasting 1% - 1% hours at 1302 hours the Deceased was airlifted to North
Devon District Hospital in Barnstaple where she died from I(a) Drowning and
Hypothermia.
4 | CIRCUMSTANCES OF THE DEATH
1. Circumstances of the death. The deceased and her family had gone swimming
in Croyde Bay in North Devon on 31% December 2013. A rip tide had taken the
deceased out to sea and as a result, a full scale search was instigated involving
the coastguard service, search and rescue helicopters and both the RMLI all-
weather lifeboat and the inshore lifeboat. The sea conditions were difficult with
a large swell and high waves. The search lasted approximately 1 hour 45
minutes until the deceased was found on the shoreline and taken by helicopter
to the North Devon District Hospital where rewarming and resuscitation attempts
were commenced but stopped after one hour. During the Inquest reference was
made to the signs displayed at Croyde beach which the family claimed they had
not seen. Those signs refer to potential hazards including rip currents. The
Inquest was told by HM Coastguards that these were the prescribed RNLI
signs. The evidence of the coastguards were that the signs could perhaps be
better displayed because the warning part of the sign could not be seen on the
entrance to the beach as the sign was erected parallel to the slipway entrance
onto the beach. The Inquest was told that there are three rip tides at Croyde,
one on either side of the bay nearest the rocks and one towards the centre
where there is a sand bar although this rip current would move depending upon
sea conditions.
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 uniess action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows, —
1. That the appropriate signage is displayed in a way that can easily be
seen on each of the entrances to the beach.
2, Whether the sign could refer to any specific riptide hazards known of at
the beach in order to warn members of the public using the beach at
different times of the year and different states of the tide, that rip tides
would be more hazardous.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have 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" December 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
Persons. The owners of the beach, North Devon District Council, Civic Centre, North
Walk, Barnstaple, Devon, EX31 1EA. Support Officer, Maritime
and Coastguard Agency, May 3/20, Spring Place, 105 Commercial Road, Southampton,
S015 1EG. Royal National Lifeboat Institute, West Quay Road, Poole, Dorset, BH15
1HZ.
| 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
tesponse, about the release or the publication of your response by the Chief Coroner.
Signed
HH.
4" November 2014
Mr John G Tomalin
HM Deputy Coroner for the Exeter and
Greater Area
Room 226
County Hail
Topsham Road
EXETER
Devon EX2 4QD
3 responses 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 and Coastguard Agency RECEIVED - 8 JAN 2015 Bay 2/05 Spring Place 105 Commercial Road iti Southampt Maritime & Southampton Coastguard Agency Mr John G Tomalin Tel: HM Deputy Coroner re Exeter and Greater Devon Coroner’s Office Room 226 Devon County Hall Your ref: Topsham Road . Our ref: Exeter : EX24QD oo . 7 January 2015 Dear Mr Tomalin . Rebecca Jodie CURTIS-SMALL Deceased — DOD 31.12.2013 Inquest: 9 October at County Hall, Topsham Road, Exeter. Regulation 28 Report | am writing to you as a follow up to my previous correspondence dated 19 December 2014 requesting a time extension for my response to you whilst | consulted other SAR colleagues. | have now completed that work. In- particular, | have spoken with the RNLI regarding their published guidance document of 2007 regarding the advice on placement of water safety signs and beach safety flags. This document was produced for the use of local authorities, beach owners and operators to assist them in specifying and installing new signs and flags as a part of their control measures to improve beach safety. The Maritime and Coastguard Agency (MCA) was a contributor to this guidance along with the National Beach Safety Council; National Water Safety Forum, and the Royal Society for the Prevention of Accidents. The exact placement, content and maintenance of the signage at Croyde Beach is not the responsibility of the MCA or the RNLI and | am unable to comment on the historical placement arrangements. With regard to evidence that the signs on this particular beach could have been better placed | do understand that the exact placement of signage is often a compromise due to demands of requirements by planning and local authorities, beach owners or operators or environmental, financial or other constraints. The MCA ‘i is - absolutely committed. to reducing the incidents of drowning through e education, supervision, rescue response and, where appropriate working with other organisations. | know that in 2015 RNLI is increasing its investment into a comprehensive, integrated, community approach to lifesaving interventions which will include working with those involved with Croyde beach.to assist with their risk assessment process to ensure, so far as is reasonably practicable, the risk is mitigated. | can assure you that MCA will proactively engage with the RNLI on this issue and offer support where necessary. Yours sincerely - Richard Martin OBE Chief Coastguard HM Coastguard _ ‘acim
Your ref: JGT/DMT File No: 2873/2013 Our ref: DH/Croyde Beach/2014 Please ask for: Diana Hill Tel: 01271 388283 o Email: Diana.hill@northdevon.gov.uk nort Cc O Date: 13" November 2014 hdevo Nn Mr J G Tomalin RECEIVED 17 NOW 2014 HM Deputy Coroner Room 226 County Hall Topsham Road EXETER EX2 4QD Dear Mr Tomalin, Rebecca Jodie CURTIS-SMALL Deceased — DOD 31.12.2013 Inquest: 9" October 2014 at County Hall, Topsham Road, Exeter. Regulation 28 Report | refer to your letter of 4 November 2014. | can confirm that the District Council has no ownership interest at Croyde Beach other than the public toilets located at Moor Lane. Signs are provided by the landowner and although the RNLI's standard format is used extensively across the country by many private landowners and councils including North Devon Council on its own beaches, it is not a legal requirement, simply in our view best practice. The District Council has some limited responsibility for signing at designated bathing beaches in accordance with the EU Bathing Water Regulations but this is very prescriptive, focusing on water quality and not safety. Even in this case, the Council as Local Authority has no enforcement powers against private landowners who are not in agreement to allow the bathing water quality sign to be erected, only the Secretary of State has such power. We are therefore unable to take any action in respect of Croyde Beach, but in light of the issues you have raised we will be undertaking an audit of signs at the beaches which are under our control and ownership and we also intend to bring this issue to the attention of our partner organisations. Yours sincerely, PAR thO Diana Hill : Head of Property & Technical Services INVESTOR IN PEOPLE
y 24 Award Winning UK Holiday Parks Owner Select Centre RECEIVED 2 2 DEC 79 Head Office ” 2nd Floor One Gosforth Park Way Gosforth Business Park Newcastle upon Tyne f NE12 8ET Your ref: as T 0344 335 3523 F 0191 268 5954 18 December 2014 Mr John Tomalin HM Deputy Coroner for the county of Devon Exeter and Greater Devon Coroner's Office Room 226 Devon County Hall Topsham Road Exeter EX2 4QD Dear Sir, Rebecca Jodie CURTIS-SMALL Deceased ~ DOD 31.12.2013 Regulation 28 Report We refer to your letter dated 4 November addressed to Parkdean Holidays — Ruda Holiday Park Ltd enclosing the Regulation 28 Report. Parkdean Holiday Parks Limited is the owner and operator of Ruda Holiday Park and the beach at Croyde, North Devon. We take our responsibilities as the owner of the beach extremely seriously and we take all reasonably practical steps to ensure the safety of beach users. We note the two matters of concern listed in the Regulation 28 Report. The signage that is displayed at Croyde Beach has been designed and erected in agreement with the RNLI and these signs are consistent with signage and information that is provided at several beaches in the North Devon area and elsewhere in England. The signs clearly state whether a lifeguard is on duty at the beach (as this varies depending on the time of year) and identifies the dangers of rip tides, offshore winds, rocks and sudden drops in sea floor. The advice provided by the RNLI relates to the content and layout of the signs and also the number and location of signs erected at the beach. Large safety and information signs are prominently displayed on each of the five access points to Croyde Beach and the exact location of these signs was discussed with the RNLI at the time the signs were erected (which pre-dates 31.12.2013). In light of the advice previously provided by the RNLI Parkdean Holidays considers the signage in place is appropriate and sufficient to provide relevant safety information to beach users. However, the company is very willing to discuss the matter further with the RNLI and act upon any recommendations which may be suggested, if any. Parkdean Holidays recognises the importance of ensuring any signage displayed is as clear and user-friendly as possible and is consistent with similar information provided at other beaches in the local area. Parkdean Holiday Parks Limited Registered in England: 4086679 Registered Office: 2nd Floor, One Gosforth Park Way, Gosforth Business Park, Newcastle upon Tyne, NE12 8ET We trust that we have provided a substantive response to the points raised in the report. If you require further information please contact us on 0191 256 0707. Yours faithfully, Solicitor Legal & Corporate Services Director
See every Prevention of Future Deaths report matching John Tomalin, 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.