Prevention of Future Deaths reports · 2015

Isaac Nash

Regulation 28 report to prevent future deaths, reference 2015-0028, written 30 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report30 Jan 2015
Reference2015-0028
DeceasedIsaac Nash
CoronerDewi Pritchard
Coroner areaNorth West Wales
CategoryOther related deaths · Child Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. The Chief Executive, Ynys Mon County Council

1 | CORONER

|am DEWI PRITCHARD JONES Senior Coroner for the coroner area North West Wales

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 28" November 2014 | commenced an investigation into the death of ISAAC NASH
Aged 12 years. The investigation concluded at the end of the inquest on 21" January
2015. The conclusion of the inquest was that the medical cause of death was drowning
and that death was due to Misadventure.

4 | CIRCUMSTANCES OF THE DEATH

On 29" August 2014 the deceased together with his parents and other members of his
family went to the beach at Aberffraw with the intention of playing on the beach and
bathing in the shallow water. The family had been to this beach on several occasions
and understood it to be a beach that is safe for children. The adult members of the party
were aware of a potential hazard in the form of a possible strong current where the river
enters the bay and therefore they located themselves some distance to the south of the
estuary. The members of the party were not aware that when they arrived at the beach
the ebbing tide was at its peak due to the tidal flow in the Irish Sea, the ebbing tide in
Aberffraw Bay and the flow of water in the river.

The deceased and his brother were playing in the shallow water of the bay but,
unfortunately, they were drawn towards the river estuary. By the time the adults realised
this the children were in an area of a strong ebbing tide. They immediately realised the
danger and went to recover the children who were being swept out to sea. Two adults
attempted to save the children but encountered strong tidal conditions with the result
that only one child was saved and the deceased was swept out to sea. The body of the
deceased was never found.

At the Inquest concern was expressed by the family and by local residents that
Aberffraw Bay is known to be a beach that is safe for children but there is no way of
warning those enjoying the beach that there is an area where the river estuary is located
where at times there can be very strong currents.

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) Whereas it is acknowledged that there is no such thing as a safe beach Aberffraw
Bay is generally considered to be a beach that is safe for children. Unfortunately, the
area where the river estuary is located is, at times, subject to very strong currents and
there is no way by which a person using the beach can be aware of this other than by
having local knowledge. In this case, the adults accompanying the deceased were
extremely sensible and safety conscious but could not have been aware of the strong
tidal conditions prevailing when the children were playing on the beach. If they had
been aware of the strong tide at that time they may either have not gone onto the beach
or would have chosen a location in the bay where the tidal stream is not great and would
have ensured that the children would not stray into the strong tidal area. | would
suggest that you consider erecting signs to warn the public of the potential danger in the

river estuary part of Aberffraw Bay.
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and

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 1* April 2015. 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.

COPIES and PUBLICATION 7
| have ot to the Chief Coroner and to the following Interested
Persons and to the LOCAL SAFEGUARDING BOARD. | have also
sent it to [I who may find it useful or of interest.

| 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.

30 January 2015 SIGNED:

DEWI PRITCHARD
SENIOR CO

Responses

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.

Response from Isle of Anglesey County Council (PDF)
YNYS MON aaa JONES, ma.
ISLE OF ANGLESEY = “=* Execute

CYNGOR SIR YNYS MON

COUNTY COUNCIL ISLE OF ANGLESEY COUNTY COUNCIL
Swyddfa'r Sir
LLANGEFNI
Ynys Mén - Anglesey
LL77 7TW

Mr Dewi Pritchard Jones LLB TEP Gofynnwch am - Please ask for: P|

oh ee emer 2

North West Wales

37 Castle Square ee
Caernarfon Ein Cyf - Our Ref. ma

Gwynedd Eich Cyf - Your Ref.
LL55 2NN

30 March 2015

Dear Mr Pritchard Jones
RE: ISAAC NASH DECEASED

| refer to your correspondence dated 30" January 2015 regarding your Inquest into
the death of Isaac Nash and your Statutory Notice under Paragraph 7 of Schedule 5
of the Coroners and Justice Act 2009.

The Isle of Anglesey County Council, acting as the relevant Local Authority in this
matter has taken the following action in response to your Notice:-

1. Senior Elected Members and Officers have held six meetings with the local
community, including three meetings with the Aberffraw Community Council
of which comprised a site visit) and discussions have also been held with

Le reer of Glan Aber at Trwyn Du itself.
2. A risk assessment has been undertaken by the Council’s Maritime Team (copy

attached for your perusal) and arrangements are in place for members of the
Maritime Team to monitor on a regular basis the lifebuoys sited on the beach
itself.

3. Following the action in 1 and 2 above, a new warning sign is to be placed in the
car park. This sign draws particular attention to the potential dangers at Trwyn
Du. In dialogue with the Aberffraw Community Council and the Bodorgan Estate,
the landowner, we have attempted to strike the right balance between the safety
issues and the local tourist industry in the village of Aberffraw.

4. It is intended that the new sign is erected during the week 30 March — 2 April and
in time for the influx of visitors to the area over the Easter Bank Holiday.

I, therefore, trust that you accept that as the Local Authority, we have engaged with
the relevant stakeholders, addressed the issues you identified in your Regulation 28
Report to Prevent Future Deaths, and that we have complied with the requirements
of your Statutory Notice.

Gwefan: www.ynysmon.gov.uk = Website: www.anglesey.gov.uk

Please contact me at your convenience if | can be of future assistance to you in this
matter.

Yours sincerely

Richard Parry Jones
Chief Executive

Encs. (copy of the risk assessment and copy of the warning sign to be erected
on site).

c.c. Monitoring Officer / Head of Council Business
C.c. Principal Development Officer (Tourism and Marketing)
Cc. Senior Solicitor

Gwefan: www.ynysmon.gov.uk ° Website: www.anglesey.gov.uk

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