Prevention of Future Deaths reports · 2016

Charles Newby

Regulation 28 report to prevent future deaths, reference 2016-0104, written 10 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Mar 2016
Reference2016-0104
DeceasedCharles Newby
CoronerMartin Fleming
Coroner areaWest Yorkshire Western
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.

IN THE WEST YORKSHIRE WESTERN CORONER'S COURT
IN THE MATTER OF:

The Inquests Touching the Death of Charles Alan Newby
A Regulation Report - Action to Prevent Future Deaths

THIS REPORT IS BEING SENT TO:

Canal River Trust

1 | CORONER

Martin Fleming HM Senior Coroner for West Yorkshire Western

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 20 of the Coroners
(Investigations) Regulations 2013

3 | INVESTIGATION and INQUEST

On 22 October 2015 I opened an inquest into the death of Charles Alan
Newby who, at the date of his death, was aged 60. The inquest was
resumed and concluded on 26 February 2016.

I found that the cause of death to be: -

la. Drowning
II Alcohol consumption

The conclusion of the inquest was Accident

4 | CIRCUMSTANCES OF THE DEATH

On 18 October 2015 Charles Alan Newby inadvertently fell from the rear
of a boat on the Calder River/Canal in Dewsbury whilst he was he was
| intoxicated with alcohol and not wearing a life jacket. Although several

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|_|

attempts were made to retrieve him from the water, he succumbed and
drowned.
CORONER’S CONCERNS

—|

During the course of the inquest the evidence revealed matters giving rise
to concem, given that there are no life rings at Lock 19 location on the
Calder Canal. In my opinion there is a risk that future deaths could occur
unless action is taken. In the circumstances it is my statutory duty to
report to you.

The MATTER OF CONCERN is as follows. —

e Iwould ask the trust to carefully re-assess the appropriateness of
the installation of life rings at the Lock 19 location.

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

L

| YOUR RESPONSE |

You are under a duty to respond to this report within 56 days of its date; I
the Coroner, may extend that period on request.

Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.

8 | COPIES

Ihave sent a copy of this report to:

_ —_

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

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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 | DATED this 10 day of March 2016

li D¥Ce_,

M. D. Fleming
Senior Coroner

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