Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0042, written 6 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2015 |
|---|---|
| Reference | 2015-0042 |
| Deceased | Jordan Roberts |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
THIS REPORT IS BEING SENT TO:
1. [EEE Finchale Abbey Farm, Finchale, Durham DH1 5SH
2. Durham County Council, County Hall, Durham City.
CORONER
tam Andrew Tweddle Senior Coroner, for the coroner area of County Durham and
Darlington
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.
(see attached sheet)
INVESTIGATION and INQUEST
On 10" September 2014 I commenced an investigation into the death of JORDAN LEE
ROBERTS, aged 17 years. The investigation concluded at the end of the inquest on 37
February 2015. The conclusion of the inquest was “Accidental Death”.
CIRCUMSTANCES OF THE DEATH
The deceased, his brother and a close family friend had been playing in the River Wear
near Finchale Abbey on Monday the 8" of September 2014. They had spent much of
| the day playing in the river without incident. The river level was quite low, it was good =|
| weather and most of the time they had been walking in the river without difficulty in water |
that was not very deep. On the afternoon one of the three noticed he was in deeper i
water, about chest height, and began swimming and when he turned round he saw the
two brothers in the river bobbing up and down in and under the water and at first thought
they were playing. When neither re-appeared above the surface he realised there was
something amiss, jumped back into the river and swam and was able to recover one of
the brothers to the river bank and following CPR this person revived. The rescuer went
back into the water but was unable to find and therefore unable to retrieve the other
brother who was subsequently found in the river in over 2 meters of water by emergency
services the next day. The rescuer had not seen any warning signs along the bank side.
The local water bailiff was able to confirm that there was one warning sign affixed quite
high up to a tree on the Finchale Abbey bank side of the river near to a picnic area
warning of deep and dangerous water. The water bailiff did not believe that there were
any warning signs on the other bank side, owned by Durham County Council. Evidence
was given that there are in fact three small signs on the Durham County Council bank
side which the water bailiff despite knowing the area well did not know they existed.
They are approximately 4 inches square bearing words “Danger do not enter water”
giving an emergency number and a County Council information telephone number. The
water bailiff confirmed that he knew of and he believed others knew of a much deeper
area of water at the place where this incident took place where the water depth falls
away sharply from being a few feet in depth to a depth of 4 meters or more. The drop is
sudden. The area is known as the bombhole. The rescuer confirmed that even though
he had played in the river in that area since childhood he was unaware of this particular
deep area. There are no warning signs near to the site of the incident. There are no
warning signs particularly highlighting the risk and dangers posed by deep water in the
area.
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
8
te —— Sooo
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(1) The depth of the water in the River Wear which the three young men waded
through is not particularly deep or particularly hazardous except where there is this
particularly deep pool where the dangers are also compounded by strong currents.
) There is one warning sign on the Finchale Abbey side of the river but people walking
down the well established river path on the County Council river bank side would be
unaware of this sign and the three small square warning signs that are in place seem
inadequate and not fit for purpose particularly bearing in mind that the water bailiff
himself was unaware of their existence. Consideration therefore should be given to the
question of the erection of appropriate warning signs on both sides of the River Wear in
this area particularly highlighting known dangers of this particularly deep expanse of
water.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you 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 3 April 2015 |, 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
t have sent a copy of my report to the Chief Coroner and to the following Interested
Persons] and to the Durham Safeguarding Board.
| tam 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.
—
6 February 2015
Andrew Tweddle
HM Senior Coroner
County Durham and Darlington
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.
Contact: m7 Direct Tel: ena: Your ref: Our ref: ~TC/CH Mr Andrew Tweddle HM Senior Coroner for County Durham and Darlington HM Coroner's Office PO Box 282 Bishop Auckland Co. Durham DL14 4FY 17 March 2015 Dear Andrew Re: Jordan Lee Roberts, deceased | refer to your letter dated 6 February 2015 regarding the warning signaga on both sides of the River Wear at Finchale Abbey. Following the tragic death of Jordan Lee Roberts, a safety assessment of the northem section of the river bank has been undertaken by Durham County Council. The assessment process has also involved a Royal Society for the Prevention of Accidents (ROSPA) consultant. ROSPA have also been engaged by the Durham City Safety Group to undertake an independent review of river safety in Durham City Centre. As part of this process, ROSPA are also reviewing various other locations across the County including Finchale Abbey. The safety assessment has resulted in actions being taken to replace the existing waming signs which were identified In the matters of concem. Larger, improved hazard waming signs have been erected at 3 key locations along the northem river bank. This will wam river path users that there are river related hazards, specifically strong currents and deep water. The signs being erected are in accordance with The Health and Safety (Safety Signs and Signals) Regulations and ROSPA national water safety signage specification for public areas. All signs will be subject to ongoing inspection and monitoring regimes and replacements will be erected on an ongoing basis where required. Furthermore, additional work will aiso be undertaken to improve sections of fencing along the northem side of river bank in the vicinity of the footbridge. Information will also be provided on the Durham County Council Cacken Wood picnic area webpages regarding the hazards associated with the river, particularly for those visiting this attraction that may be unaware. Continued... Neighbourhood Services Durham County Council, County Hall, Durham DH1 5UQ Main Telephone (03000) 260 0000 Minicom (0191) 383 3802 www durham.gov.uk iso |251¢ Council of the Year Page 2 of 2 In order to raise as much awareness as possible to the dangers of the river, the actions being taken by the Council on the Northem side of the river bank have also been communicated to the adjacent landownedi, at a site meeting on 27 February 2015. Should you require any additional information do not hesitate to contact me. Yours sincerely, Corporate Director, Neighbourhood Services
See every Prevention of Future Deaths report matching Andrew Tweddle, 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.