Prevention of Future Deaths reports · 2015

Robbie Williamson

Regulation 28 report to prevent future deaths, reference 2015-0105, written 12 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Mar 2015
Reference2015-0105
DeceasedRobbie Williamson
CoronerRichard Taylor
Coroner areaLancashire (East)
CategoryChild Death (from 2015) · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

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.

Richard G. Taylor
Senior Coroner for East Lancashire District

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: Wales and West Utilities; Northern Gas Network;
Scotia Gas Network; The Chair of the Association of Independent Gas Transporters.

CORONER

lam Richard G. Taylor, Senior Coroner for East Lancashire District

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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
htto:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 24/04/2014 | commenced an investigation into the death of Robbie Mark Williamson then
aged 11. The investigation concluded at the end of the inquest on 04 March 2015. The
conclusion of the inquest was Accidental death. On 22 April 2014 Robbie Mark Williamson fell
from an exposed pipe into the canal. The medical cause of death being drowning.

CIRCUMSTANCES OF THE DEATH

On the 22" April 2014 Robbie was with two school friends when they dared each other to cross
the canal by walking across an exposed cast iron gas pipe attached to the outside of a road
bridge. The surface of the pipe was wet and slippery. There was no sign warning that there
should be no access to the pipe. There were no obstacles to prevent access to the pipe. Robbie
slipped whilst crossing and fell into the canal injuring himself on the canal bank as he did so. He
was in the water a number of minutes before being pulled from the canal, where after he
teceived medical treatment before being pronounced dead at Royal Blackburn Hospital the same
day. offered medical cause of death as;

4 (a) Drowning
2 Head injury

National Grid accepted they were responsible for the pipe line. Evidence was heard that they
control approximately :a quarter of pipelines countrywide. Their own database had shown that
this pipe was under the pavement. Since Robbie's death they have made the pipe safe and also
commenced an investigation into the safety of the piping they control.

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) There may be exposed raised pipework for which you are responsible, either attached to
bridges or otherwise, that is accessible to members of the public.

Lyndhurst House, 30 Todmorden Road, Burnley, Lancashire, BB10 4AB
. Tel 01282 838356 | Fax 01282 425041

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
42 March 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

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
| RE 8 ob0ie's Father)

2. BR Robbie's mother)
3. (41.S.c. Energy Division)

| am 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,

Dated 12 March 2015

Signature fll —
Mr. Richard G. Taylor ,

Senior Coroner for East Lancashire District

Lyndhurst House, 30 Todmorden Road, Burnley, Lancashire, BB10 4AB
Tel 01282 838356 | Fax 01282 425041

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