Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0243, written 26 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2015 |
|---|---|
| Reference | 2015-0243 |
| Deceased | Summer Robertson and Alice Barnett |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Joanne Smithson Chief Executive Lattitude Global Volunteering 42 Queens Road Reading RG1 4BB CORONER I am John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin CORONER’S LEGAL POWERS I 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 19th December 2014 I commenced an investigation into the deaths of Summer Leigh Robertson, 21 years of age, and Alice Rebecca Barnett, 19 years of age, who died in the sea in the Indian Ocean off Woody Cape, South Africa on the evening of Thursday 4th December 2014. The investigation concluded at the end of the inquests on 1st June 2015. The conclusions of the inquests were that the two deceased, with three others, entered the sea, wading, not swimming, when they were caught in a rip current. They could not escape the rip current and died in the sea. The three others managed to survive. Miss Robertson’s body was recovered that evening and Miss Barnett’s the following morning by rescuers from the National Sea Rescue Institute. CIRCUMSTANCES OF THE DEATH The two deceased were volunteers with your charity (Lattitude). They were on a debrief session following a ten week volunteering season in South Africa. The debrief took place at the Woody Cape backpackers hostel. On the evening of the 4th December 2014 the two deceased and four others went from the hostel and five waded in the sea. The sixth person stayed onshore and watched. Whilst wading, not swimming, all five were caught in a rip current. Three of the five managed to survive but the two deceased did not and died in the sea. 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) The two deceased and the three survivors when entering the sea were unaware of the presence of a rip current and the risk that by wading, not swimming, they could put themselves in danger. (2) Lattitude was similarly unaware of the presence and risk of a rip current. Whilst there was a generic risk assessment of swimming there was no specific risk assessment as to rip currents and that they could pose a danger to anyone entering the water, whether wading or swimming. (3) Expert evidence given at the inquests indicated that the area of the coast where these tragedies occurred was, by virtue of their characteristics, likely to be subject to rip currents. The expert, of Plymouth University, provided written and oral evidence to the inquests and his report should be referred to in full. (4) In essence there is an ever present danger or risk of rip currents along this stretch of coast (and other parts in the world) and local knowledge was essential in order to identify those risks. The risk could be to a whole stretch of beach, yet at different places and at different times, pose greater or lesser risk. (5) In addition to local knowledge advice from the local or the nearest NSRI station should be sought. It was information which would be readily available on the NSRI website. (6) Anyone entering the water should be warned or made aware of the presence or possible presence of a rip current by whatever means are reasonable and appropriate for the location. (7) Similarly anyone with responsibility for those entering the water should first ascertain whether there is such a risk. (8) It was clear from the expert evidence that these risks apply in many other parts of the world and are not specific to this stretch of ocean. (9) It was not clear how best someone should seek to escape from a rip current if caught in one. If there is a minimum course of action which is likely to save life it should be ascertained and incorporated within any warnings as to rip currents as appropriate. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 21st August 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 6 7 8 1. Bond Dickinson, Solicitors for both families. 2. 3. 4. 5. of Plymouth University NSRI (South Africa) RNLI (UK) the Foreign and Commonwealth Office 6. , University of New South Wales, Australia who may find it useful or of interest. 7. The Manager, Woodycape Lodge, Portion 1 of the Farm Midfor no.327, Alexandria, 6185, South Africa. I 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. 9 26th June 2015 John Penhale ELLERY
See every Prevention of Future Deaths report matching John Ellery, 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.