Prevention of Future Deaths reports · 2015

Daniel Hodgin

Regulation 28 report to prevent future deaths, reference 2015-0146, written 20 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Apr 2015
Reference2015-0146
DeceasedDaniel Hodgin
CoronerJohn Ellery
Coroner areaShropshire, Telford & Wrekin
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

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

THIS REPORT IS BEING SENT TO:

Head of Environmental Maintenance
Shropshire Council

107 Longden Road

Shrewsbury SY3 9EL

2,
= = eam Leader} Professional Support

Legal Services

Richard Fairclough House
Knutsford Road
Warrington WA4 1HG

CORONER

lam John Penhale Ellery, Senior Coroner for the coroner area of Shropshire, Telford &
Wrekin

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.

INVESTIGATION and INQUEST

On the 31% December 2014 | commenced an investigation into the death of Daniel Lee
HODGIN deceased, 20 years old. The investigation concluded at the end of the inquest
on the 14" April 2015 at the Shrewsbury Coroners Court. The conclusion of the inquest
was accidental death. The medical cause of death was:

1a) Immersion in water

CIRCUMSTANCES OF THE DEATH

The body of the deceased was found in the River Severn at Cressage on the 31%
December 2014. The deceased had last been seen alive on Sunday morning the 234
November 2014 at 05:27 when he was recorded on a CCTV camera outside a property
at Dorset Street, Castlefields, Shrewsbury near to the River Severn in Shrewsbury. The
distance from the River Severn by Dorset Street to Cressage was 24 miles down-
stream. The deceased had been ona night out in Shrewsbury with friends and had
become lost and disorientated. The post mortem and toxicology tests indicated a level
of 196 mg/dl which represented a high level of alcohol in his body at the time of death.
It is more likely than not that at soon after this last sighting the deceased made his way
through an open gate and went the short distance down a flight of steps on to the
towpath by the River Severn which was then in flood and covered the towpath. It was
dark and the deceased had not been to that area before. It is likely that once on the
towpath he either stepped off or slipped into the river drowning or suffering fatal shock
from entering the cold water.

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) According to a Shropshire Council plan of the Dorset Street area the gate at
Dorset Street leading to the towpath should have been closed and locked
when the water level at the Welsh Bridge gauge reached 1.95 meters.

(2) At between 5 a.m. and 6 a.m. on the 23" November 2014 when the deceased
most likely entered the water, the level at the Welsh Bridge gauge was
recorded at between 2.00 and 1.99 meters.

(3) Had the gate been closed and locked the deceased would have been unable
to pass through.

(4) No clear system was established whereby the Environment Agency notified,
or was required to notify, Shropshire Council as to the water level or
likelihood of the water level reaching 1.95 meters at the Welsh Bridge gauge.
The Council’s instruction to close and Jock the gate at Dorset Street was
bound to fail, there being no effective system in place to achieve the same.

(5) River safety in Shrewsbury has been a matter of concern for some time. In
2010 i made what were then two Regulation 43 Reports to Shropshire Council
in respect of alcohol related deaths.

(6) The concerns raised here not only affect those adversely affected by alcohol
but anyone who may be unfamiliar with the area when the river is in flood
and is dangerously high covering the towpath. For completeness, and this
does not directly concern the Environment Agency, there was a recent
reported incident of a pram being blown into the River Severn where the
towpath was unprotected by railings.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you 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 15th June 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

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons.

— mother of deceased.

TR — father of deceased

1.
2,
3. Inspector of West Mercia Police, Shrewsbury Police Station
4. The Chief Coroner, His Honour Judge Peter Thornton QC

[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.

20" April 2015 ‘ohn Penhale Ellery

Responses

2 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.

Response from Environment Agency (PDF)
creating a better place Environment
Agency

15 June 2015 (\

Mr J. P Ellery

“Her Majesty’s Senior Coroner for Shropshire, Telford and Wrekin Area

H. M. Coroner’s Service
3 Floor Guildhall
Frankwell Quay
Shrewsbury

SY3 8HQ

Veg Me Aly

Re: Daniel Lee Hodgin deceased
Inquest 14 April 2015 at the Coroner’s Court, Shirehall, Abbey Foregate, Shrewsbury

Thank you for your letter of 20 April enclosing a report under Regulation 28 of the Coroners’
(Investigation) Rules 2013: | was very sorry to hear of Mr Hodgin’s death and, on behalf of the
Environment Agency, | extend my condolences to his family.

You express concern in your report that “No clear system was established whereby the Environment
Agency notified, or was required to notify, Shropshire Council as to the water level or likelihood of the
water level reaching 1.95 meters at the Welsh Bridge gauge.”.Our response is as follows:

The Environment Agency is a non- departmental public body, established by the Environment Act
1995. It undertakes a wide range of activities to protect and enhance the environment under
statutory powers and duties. These include a flood and coastal risk management role.

This flood and coastal risk management role includes a statutory power to provide and operate flood
warning systems under section 166 of the Water Resources Act 1991.

The purpose of the flood warning system we operate is to reduce the impact and effects of flooding
on people and property. A direct warning service is offered to some communities when flooding is
possible or expected. We send messages directly to those who sign up for this service by a text
message or phone call to the numbers they have provided.

A ‘Flood Alert’ will be issued to customers in Shrewsbury for the River Severn in Shropshire when the
river level monitoring gauge at Welsh Bridge is forecast to exceed a level of 2.7m ALD (At Local
Datum).

Environment Agency Page 1 of 2
Horizon House, Deanery Road, Bristol, BS1 SAH

Tel: 01903 832268

www.gov.uk/environment-agency

Executive Assistant to Jonathan Robinson: Michele Perry — michele.perry@ environment-agency.gov.uk

C)

INVESTOR IN PEOPLE,

This is the lowest threshold of direct warning for the town which was agreed historically in

consultation with the Shrewsbury Flood Forum. It is when roads, homes and businesses generally
Start to get affected by flooding in the town.

We understand that people and organisations in Shrewsbury and elsewhere along the river Severn
may be interested in a wider range of water levels.

These interests include boat Owners, marinas or operators of infrastructure such as Shropshire
Council. We operate a live river level service on the internet for this purpose.

We have spoken to Shropshire County Council to help them make full use of the information that we
provide. We have produced a technical briefing note for the council, to help them implement a
system for closing the gate at Dorset Street using the live information we put on the internet.. The
briefing note is enclosed with this letter.

Yous J a4
ie afhutol —s

Jonathan Robinson
Executive Director Resources & Legal Services

Enc: Technical Briefing Note: Dorset Street Gate, Shrewsbury

Environment Agency

Horizon House, Deanery Road, Bristol, BS1 SAH
Tel: 01903 832268

www.gov.uk/ environment-agency

Executive Assistant to Jonathan Robinson: Michele Perry — michele. perry@environment-agency.gov.uk

Page 2 of 2
Response from Shropshire Council (PDF)
Shropshire

Council

Mr J P Ellery

Senior Coroner for Shropshire, Telford and Wrekin Area
HM Coroners Service

Shirehall

Abbey Foregate

Shrewsbury

SY2 6ND

Date: 20" July 2015
uy ref

Dear Mr Ellery

Mr Daniel Lee Hodgin
Coroner’s Regulation 28 Report
Inquest 14" April 2015 at the Coroners Court, Shirehall, Shrewsbury

Further to your letter of 20" April 201 5 and the attached Regulation 28 Report sent for
Shropshire Council's attention.

Firstly | apologise for the delay in this report. There have been a number of things to
resolve in order to respond as fully as | can. There are still some matters that require
further consideration.

During the course of the inquest into the death of Mr Daniel Lee Hodgin of 14% April 2015
at the Coroners Court, Abbey Foregate, Shrewsbury, you found evidence that gave rise to
concerns. Those concerns reproduced below for ease of reference:

The matters of concern are as follows:-

(1) According to a Shropshire Council plan of the Dorset Street area the gate at Dorset
Street leading to the towpath should have been closed and locked when the water
level at the Welsh Bridge gauge reached 1.95 meters.

(2) At between 5am and 6am on the 23" November 2014 when the deceased most
likely entered the water, the level at the Welsh Bridge gauge was recorded at
between 2.00 and 1.99 meters.

(3) Had the gate been closed and locked the deceased would have been unable to
pass through.

www.shropshire.gov.uk

General Enquiries: 0345 678 9000

Printed on recycled paper

(4) No clear system was established whereby the Environment Agency notified, or was
required to notify, Shropshire Council as to the water level or likelihood of the water
level reaching 1.95 meters at the Welsh Bridge gauge. The Council's instruction to
close and lock the gate at Dorset Street was bound to fail, there being no effective
system in please to achieve the same.

(5) River safety in Shrewsbury has been a matter of concern for some time. In 2010 |
made what were then two Regulation 43 Reports to Shropshire Council in respect
of alcohol related deaths.

(6) The concerns raised here not only affect those adversely affected by alcohol but
anyone who may be unfamiliar with the area when the river is in flood and is
dangerously high covering the towpath. For completeness, and this does not
directly concern the Environment Agency, there was a recent reported incident of a
pram being blown into the River Severn where the towpath was unprotected by
railings.

Following the issue of the Regulation 28 Report discussions have taken place with a
number of parties who have an input into insuring river safety in Shrewsbury and with the
Environment Agency with respect to the issues of concern and in particular item 4.
Historically, the Environment Agency issues a “Flood Alert” when river levels at the Welsh
Bridge monitoring gauge are forecast to exceed 2.7meters. It is at this level and above
that road closures need to start to be implemented. Warnings are not issued below 2.7
meters.

The Environment Agency have, however, been looking at the relationship between river
levels at their Montford Bridge river level gauge and the Welsh Bridge gauge. We have
asked that they work to levels of 1.6 meters at the Welsh Bridge gauge, to be on the
cautious side. Their analysis indicates that when levels reach 2.78 meters at Montford
Bridge, then the levels will exceed 1.6 meters at the Welsh Bridge within 4 to 8 hours. The
Environment Agency is unable, at this time, to provide flood warnings for levels of 1.6
meters, but they do have regularly updated “river levels”, shown on their website.
Shropshire Council have engaged the services of local software company to assist in
taking the information from the website and generating automatic “alerts” when levels
reach 2.78 meters at the Montford Bridge gauge. At the time of this reply to the Regulation
28 Report this development work has not been completed. It is our intention to send a
SMS (text) message to; the Central Highways Emergency Phone (operated 24 hours a
day 365 days per year by a Highways Technician, who is familiar with all gate locations on
the River Severn in Shrewsbury and the closure procedures), the Police Control Room,
Shropshire Councils Emergency Planning Unit on call phone and the Shropshire Council
Car Park Commissioner. It is believed that through this process the necessary people will
get notification to ensure timely closure of the gates, before the towpath is likely to be
submerged in flood waters.

The closure of the gates is only part of the issue surrounding river safety and through
consideration of previous Regulation 43 Reports to Shropshire Council and our desire to
continually improve safety, Shropshire Council continue to review river safety. In January
this year, | visited the river in the evening with the Police Chief Inspector, Town Centre
Inspector and the Town Clerk for Shrewsbury Town Council. It was felt that these are the
parties which might work more effectively together to improve river safety. The Town
Council provide the lighting along the towpath. At that time we had developed an
embryonic “Team Shrewsbury” approach to protecting public realm, addressing issues
such as; drugs misuse, antisocial behaviour, environmental crime and other criminal
activity, by working more closely together. It was felt that river safety leant itself to this
approach. A specific River Safety action plan was developed and is being implemented.
The team meet weekly on an Operational basis, monthly as a Tactical Group and quarterly
as a Strategic Group. The membership of each group varies in line with the outcomes
sought. A Senior Officer from one of the three principal members attends the Operations
Meeting, most attend Tactical meetings and all the Strategic ones. River safety is a
standing agenda item. There is also a specific River Safety meeting following the
Strategic meeting which is attended by the Town Centre Inspector, Town Clerk and
myself. It is felt that this brings together the necessary people to share or call on
resources to improve safety, for example | can involve Shropshire Councils Licencing
team, if it was perceived there is a particularly problem premises, it also provides
governance around river safety decisions.

From concern numbered 6 from your Regulation 28 Report it is understood that
consideration be given to additional barriers along the towpath. The area of particular
concern, to both yourself and myself, is the length from the English Bridge down to the
Weir. My concerns are raised further with the development of a University in the town,
particularly as properties in the Castlefields area lend themselves to student
accommodation. To this end | have requested a structural report on the integrity of the
towpath facing wall. We have had a collapse in another part of town and have to
undertake regular maintenance on this section of most concern. With that information we
can determine what is possible or what needs to be done to make it possible. In the
meantime we have reviewed the existing provision and added or improved barriers as felt
necessary.

If we were to increase the provision of barriers we would need to consider the implications
that we would have. This is an extremely well used level route, used by cyclists and
pedestrians from a centre of population to the heart of the town. It avoids the hill up into
the town and keeps people away from vehicle emmissions. Whenever it is closed | am put
under tremendous pressure from Councillors and the public alike to get it open before we
have had a chance to clean silt and debris from the path. With barriers, removal of debris,
particularly large trees, would take longer, extending any closures. Barriers would be
vulnerable to damage from floating trees in times of flood, with maintenance again
extending closures. However, with an informed engineering judgement we can balance ail
the conflicting requirements. | am afraid | will have to report further once | have the
structural report.

In addition to the above we are looking to provide CCTV cameras, one looking up from the
Railway Bridge to the English Bridge, one looking down the Weir. These will be high
resolution cameras that feed into the CCTV Control Room and will be fitted with alerts that
can be set to identify loitering on the towpath and hopefully will be provided with software
that is capable of spotting potential bodies in the river and monitor river levels. This will
happen in tandem with the work on the Environmental Agency monitoring gauges. We are
in early discussions with the suppliers but they are confident they will be able to deliver
this. The Town Council are halfway through a programme of upgrading the light and have
increased the number of columns (there are now at 27 meters centres, rather than 50
meters) and will be fitted with LED lanterns, which will provide a white light rather than the
yellow of the traditional SOx lamps, which will be easier to see at night with a better
definition of the towpath edge because of the improved colour rendition.

The structural report is not yet completed, once | am in possession of that | will update you
immediately. | hope the proposals for dealing with alarms, when levels are likely to cause
flooding of the towpath, will mean that there is adequate notification to allow existing gates
to be closed.

| trust the above is of assistance and helps to address the concerns raised in your
Regulation 28 Report. If you wish to discuss this further or there is anything else | can do
to assist, please do not hesitate to contact me directly in the number below.

Yours sincerely

r Tim Sneddon
Operations Manager
Environmental Maintenance Shropshire Council.

01743 252819

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