Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0154, written 22 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2015 |
|---|---|
| Reference | 2015-0154 |
| Deceased | Jack Rowe |
| Coroner | Claire Balysz |
| Coroner area | Wiltshire & Swindon |
| Category | Child Death (from 2015) |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Parliamentary Under Secretary of State for Children & Families Sanctuary Buildings 20 Great Smith Street WESTMINSTER London SW1P 3BT The Secretary of State for Communities and Local Government 2 Marsham Street London SW1P 4DF 1 | CORONER | am Claire Balysz, Assistant Coroner, for the Coroner area of Wiltshire & Swindon 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 15 July 2014 an investigation was commenced following the death of a 3 year old boy who was found lying at the bottom of a family swimming pool. The Inquest was concluded on the 15 April 2015. My conclusion at Inquest was that Jack died as the result of an accident and the cause of death was 1a) Multi organ failure with bronchopneumonia following an out of hospital cardiac arrest b) Immersion in water (drowning) CIRCUMSTANCES OF THE DEATH On 9 July, Jack’s mother left him in the care of his 20 year old brother whilst she took her daughters to a school disco, having done so on previous occasions. Jack was watching a DVD with his brother when she left. Roughly half an hour later she received a call from her step son saying that Jack was missing. After a search his body was found at the bottom of the family swimming pool. Jack had previously not shown any interest in the swimming pool and had to be encouraged to go in. However, the previous Saturday he had been watching his friend play by hitting the surface of the water with a toy brush. This brush was found floating in the swimming pool when Jack was discovered. The swimming pool was not fenced. 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. — | received evidence that in Australia and France it is compulsory to fence private swimming pools with child resistant barriers. | am concerned that the lack of regulations in the UK could contribute to future death from children drowning in unfenced swimming ools. ACTION SHOULD BE TAKEN To review law and building control for existing and new pools to consider making it compulsory to have child resistant barriers around private swimming pools as it is in Australia and France. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 June 2015. |, the Assistant 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 © 2ron's and RoSPA, Birmingham. lam 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. 22 April 2015 Dr. Claire Balysz Assistant Coroner for Wiltshire & Swindon
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.
ob James Wharton MP AES Minister for Communities Department for Department for Communities and'Locaf——~~= ~~ vy G t Communities and Fry Building Local Government oe SW1P 4DF Dr Claire Balysz HM Coroner for Wiltshire and Swindon re “fe Ans ae ax: ican Street E-Mail: james.wharton@communities.gsi.gov.uk Wiltshire www.gov.uk/delg SP1 1DP Our Ref: 1019390 Your Ref: LZu La & - 16 JUN 208 Jack ROWE deceasetl- aged 3 years Thank you for your letter of 22 April to the Secretary of State for Communities and Loca! Government, attaching a Regulation 28 Report touching the death of 3 year old Jack Rowe. ! have been asked to reply as | have responsibility for the Building Regulations. | was very sorry indeed to learn of Mr and Mrs Rowe’s tragic loss. Please convey my condolences to them. Sadly, it is a tragic fact that each year around 15 young children drown at residential locations. Of these, a small number, two or three, occur in a swimming pool. On the leisure safety section of its website www.rospa.com, the Royal Society for the Prevention of Accidents (RoSPA) recommends that pools should be fenced to ensure that young children who escape supervision cannot gain access to the water. However, they note that fencing is only a partial solution and that the key to pool safety is supervision if children are in the vicinity. We take the view that building regulations would not be the best way to ensure that swimming pools are safe, as they apply only where building work takes place. The definition of a building for the purposes of the regulations does not currently cover an outdoor pool. Furthermore, as the regulations only cover new work, they could not be applied retrospectively to existing pools. Also, any requirement would be very difficult to enforce as it would not be possible to prevent fences from being removed after installation. Instead, it is expected that owners/occupiers will be responsible for the safety of people upon their property, identifying hazards and seeking to reduce them by implementing the kind of straightforward measures advised by RoSPA. The Health and Safety Executive (HSE) publication Managing Health and Safety in Swimming Pools (HSG179), which provides guidance for commercial swimming pools, can also be used for domestic swimming pools. The Government therefore does not consider that new building regulations would be the answer. Thank you for writing. As always, these matters are kept under review and your findings are a valued contribution to that process. pon daa Lv LEME JAMES WHARTON MP ____ et Laer
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