Prevention of Future Deaths reports · 2016
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 report | 11 Jan 2016 |
|---|---|
| Reference | 2016-0007 |
| Deceased | Nicholas Milligan |
| Coroner | Elizabeth Carlyon |
| Coroner area | Cornwall |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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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