Prevention of Future Deaths reports · 2016

Daniel Willington

Regulation 28 report to prevent future deaths, reference 2016 – 0396, written 10 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Nov 2016
Reference2016 – 0396
DeceasedDaniel Willington
CoronerJonathan Layton
Coroner areaCarmarthenshire and Pembrokeshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. 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: 

1.  Chief Executive Maritime and Coastguard Agency, Head Office, Spring 

Place, 105 Commercial Road Southampton, SO15 1EG 

1 

CORONER 

I am Jonathan Mark Layton Senior Coroner, for the coroner area of Carmarthenshire 
and Pembrokeshire. 

2 

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. 

3 

INVESTIGATION and INQUEST 

On 29th April 2016 I opened an investigation into the death of Gareth Willington and on 
the 24th October 2016 I opened an investigation into the death of Daniel James 
Willington. The investigation concluded at the end of the inquest on 10th November 
2016. The conclusion of the inquest was accidental death in relation to Daniel James 
Willington and misadventure in relation to Gareth Willington.  

4 

CIRCUMSTANCES OF THE DEATHS 

(1)  On 28th April 2016 Gareth Willington and his son Daniel James Willington left 
their homes to go out on their fishing boat called Harvester leaving Milford 
Haven Docks in the early hours. 

(2)  At 14.30 hours that day the coastguard received calls in relation to a fishing boat 

in difficulty near Abereiddy. 

(3)  The emergency services were alerted and a full scale search was commenced 

in the area. 

(4)  At 18.00 hours Mr Gareth Willington was recovered from the sea and taken to 

Withybush General Hospital where life was pronounced extinct. 

(5)  The body of Mr Daniel James Willington was not recovered. 
(6)  A report from the MAIB concluded that Mr Daniel Willington had become 

entangled in the back rope and Mr Gareth Willington had come to his assistance 
resulting in both men going overboard. 

(7)  Neither crew member was wearing a personal flotation device at the time of the 

accident. 
CORONER’S CONCERNS 

5 

During the course of the inquest the evidence revealed this matter 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 is as follows: 

That the wearing of personal flotation devices whilst on deck is not mandatory.  The 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 report from the MAIB in their report no 22/2016 states “the benefits of wearing PFDs on 
the exposed decks of fishing vessels are incontrovertible”.  Legislation requiring the 
compulsory wearing of personal flotation devices on the working decks of fishing vessels 
while at sea would lead to a reduction in the number of deaths at sea. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 5th January 2017. 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: 

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 

10 November 2016                                             Signed: J M Layton 

2

Responses

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.

Response from Maritime and Coastguard Agency (PDF)
Bay 3/30
Ed Spring Place
105 Commercial Road
ss South tO!
Maritime & Soi Ize
Coastguard United Kingdom

E-mail:
Mark Layton

HM Senior Coroner Your ref:
Carmarthenshire and Pembrokeshire Our ref: CE 49/2016
Coroner's Office 21 December 2016
Town Hall

Hamilton Terrace

Milford Haven

Pembrokeshire

SA73 3JW

Dear Mark

INQUEST INTO THE DEATHS OF MR GARETH WILLINGTON AND MR DANIEL
JAMES WILLINGTON

Thank you for your letter of 10 November 2016 attaching the Regulation 28 Report
containing your conclusions of the inquest.

! would like to address the matter of concern in your report:

That the wearing of personal flotation devices whilst on deck is not
mandatory. The report from the MAIB in their report no. 22/2016 states “the
benefits of wearing PFDs on the exposed decks of fishing vessels are
incontrovertible”. Legislation requiring the compulsory wearing of personal
flotation devices on the working deck of fishing vessels whilst at sea would
lead to a reduction in the number of deaths at sea.”

Your report also recommends that MCA should take action to prevent future deaths.

The Marine Accident investigation Branch in their Investigation Report No 21/2016
into a Man Overboard from the Annie T recommended that MCA:

Prioritise the introduction of legislation that will require the compulsory
wearing of flotation devices on the working decks of all fishing vessels.

In response to this report, the MCA is reviewing, as a high priority, the current
policies around wearing personal flotation devices and considering what additional
steps, including the development of legislation, could be taken.

This work will require the input of all fishing stakeholders and we will provide an
update to both the recommendation of the MAIB and your report in early 2017,
following an extraordinary meeting of the Fishing Industry Safety Group convened by
the MCA on 11 January 2017.

Yours sincerely

Sir Alan Massey
Chief Executive

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