Prevention of Future Deaths reports · 2016

Nicholas Milligan

Regulation 28 report to prevent future deaths, reference 2016-0007, written 11 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report11 Jan 2016
Reference2016-0007
DeceasedNicholas Milligan
CoronerElizabeth Carlyon
Coroner areaCornwall
CategoryOther 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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

The Royal Yachting Association (RYA)
British Marine Federation

CORONER

| am the Senior Coroner for the coroner area of Cornwall

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

Emily Charlotte Milligan and Nicholas Desmond Robertson Milligan

CIRCUMSTANCES OF THE DEATH

On the 5" May 2013 Nicholas Milligan was on holiday in Cornwall with his family
(including Emily Milligan). The whole family went out in the family boat “Milly” a
8M Cobra ridge hulled inflatable boat with a 300 HP engine from about 12.30 pm
that day around the Camel Estuary Nicholas Milligan was at the helm in the
camel estuary north of Padstow when at around 15.46 the occupants of the boat
were ejected following a high power turn. The boat continued to circle repeatedly
and hit both Emily and Nicholas resulting in fatal injuries from which they died. Mr
Milligan had not got the kill cord attached at the time of the ejection which
resulted in the engine not being immobilised. Mr and Mrs Milligan had completed
their Speedboat Courses.

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. —
There has been an increase in the speed/power of such power boat leisure craft

which create additional risks which users should be aware of to prevent
accidents.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have the power to take such action.

To review the level of training required for users of high performance power boat
leisure craft to reduce the risk of future accidents

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 11 March 2016. |, 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

| 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.

11 January 2016 Dr E E Carlyon

Cugabetl, nme @Myen

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