Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0132, written 29 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Mar 2016 |
|---|---|
| Reference | 2016-0132 |
| Deceased | Adam Miles |
| Coroner | David Urpeth |
| Coroner area | South Yorkshire (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Hilton Hotel, Victoria Quays, Furnival Road, Sheffield, S4 7YA 2. British Waterways, Canal & River Trust, Head Office, First Floor North, Station House, 500 Elder Gate, Milton Keynes, MK9 1BB 1 CORONER I am David Urpeth Assistant coroner, for the coroner area of South Yorkshire West 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 16.12.15, I commenced an investigation into the death of Adam Ben Miles (Aged 20). The investigation concluded at the end of the inquest on 24.3.16. The conclusion of the inquest was Accidental Death. The medical cause of death was drowning to which alcohol intoxication contributed. 4 CIRCUMSTANCES OF THE DEATH On 12.12.15, Mr Miles was attending a Christmas party at the Hilton Hotel in Sheffield. At 21.48 he was seen on CCTV footage to leave the hotel by the rear door leading to the canal basin. Other CCTV footage showed Mr Mikes on the phone and smoking a cigarette. He stepped over a low chain and was seen to fall into the canal where he drowned. 5 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That smokers were allowed to smoke outside the hotel near the canal. (2) That there wasn't any rails or other effective barriers to segregate drinkers from the dangers of the canal (3) That the canal didn't have any means of escape for anyone who fell in. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 15th June 2016. 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. 1 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family as 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 29th March 2016 David Urpeth 2
2 responses 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.
Canal & m= <a River Trust Keeping people, nature & history connected 14th June 2016 Mr David Urpeth HM Assistant Coroner The Medico-Legal Centre Watery Street Sheffield $3 7ET Dear Mr Urpeth Re: Adam Ben Miles (deceased) Thank you for your letter and report of the 5" April 2016 regarding the inquest into the death of Mr Adam Ben Miles. On behalf of the Canal & River Trust (‘the Trust’) | would like to offer our sincere condolences to the family of Mr Miles. | understand that in your report, under paragraph 7, schedule 5 of the Coroners & Justice Act 2009 and Regulations 28 & 29 of the Coroners (Investigations) Regulations 2103 addressed to Canal & River Trust, Station House, Milton Keynes, you have specifically asked for a review of the following matters of concern: e That smokers were allowed to smoke outside the hotel near the canal; e There wasn't any rails or other effective barriers to segregate drinkers from the danger of the canal; e That the canal didn’t have any means of escape for anyone who fell in. On the 3% May 2016 one of the Trust’s safety advisors visited Victoria Quays and it’s immediate surroundings. Together, he and | have reviewed the matters of concern outlined above and conducted a risk assessment. During the risk assessment we applied the Trust's guidance on the appropriateness of segregation of the public from the canal basin, rescue equipment (such as a life rings and escape ladders), and the ability of a person to ‘self-rescue’. We came to the following conclusions: Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB www.canalrivertrust.org.uk Patron: H.R.H. The Prince of Wales. Canal & River Trust, a charitable company limited by guarantee registered in England and Wales with company number 7807276 and registered charity number 1146792, registered office address First Floor North, Station House, 500 Elder Gate, Milton Keynes MK9 1BB e The proximity of smokers and drinkers from the hotel to the canal. We believe that moving the smoking area from the rear of the hotel to the front will significantly reduce the risk of hotel customers unintentionally being in close proximity of the canal. e Effectiveness of barriers. The level of segregation at Victoria Quays necessarily varies because this is dependant on the activity in the different sections of the canal basin and the land immediately adjacent to the canal. We have reviewed this situation and believe it is appropriate for the intended use of the basin and its surroundings, which remains very much an operational waterway. The chains and barriers have difference purposes: the chains are for demarcation only (and primarily for vehicles at that), and they are not intended to exclude people from accessing the waterway because e.g. boaters are allowed to moor in this area; the barriers are intended to exclude people from the edge of the waterway and appear to do so adequately. We also believe lighting in the canal basin is sufficient and we note it is augmented by the lighting on adjacent land. ¢ Means of escape for anyone who fell in. At the time of the incident, there were (and still are) two escape ladders provided in the basin, leading from the water. The ladders were positioned so that they will not be obstructed by the boats mooring in the basin. importantly, the ‘freeboard’ edges of the basin are also maintained at a height of approximately 400mm from the level of the water itself to allow ‘self-rescue’ in circumstances where a person who falls into the water is capable of staying afloat. Life rings are also located at intervals around the basin for persons who need assistance to float, in accordance with national guidance. However, we have reviewed the number and positioning of the existing life rings and propose to place two additional life rings on the side of the basin closest to the hotel, purely as an additional precautionary measure. e We have reviewed the safety signage and whilst we believe it was adequate according to our usual standards and national guidance, we propose placing additional “Danger deep water” signs at locations around the basin because, unlike the canal, which is typically 4-5 feet deep at the edge, the basin is some 10 to 12 feet deep. Overall we believe these additional measures will further reduce the risk of further tragedies. We will continue to review our risk assessments and national guidance which should identify if further measures are required, in which case appropriate action will be taken. If you require any further information please contact me. Yours sincerely Head of Health and Safety Canal & River Trust
13” June 2016 @ Hilton SHEFFIELD eset The Assistant Coroner The Medico-Legal Centre Re: Adam Ben Miles (deceased) Thank you for your letter dated 5 April 2016 and the enclosed Regulation 28 Report to Prevent Future Deaths (“the Report’) concerning the inquest into the death of Mr Adam Ben Miles which was addressed to: 4. Hilton Sheffield (“the Hotel”); and 2. British Waterways, Canal & River Trust. | have read your report with care and in particular the concerns you have raised as a result of your investigation into Mr Miles's death. | have also discussed this report with our Safety and Security team. 1 have detailed below, the measures which the Hotel currently has in place and also further measures that the Hotel is in the process of implementing: There is no designated smoking area on the canal side of the Hotel. The designated smoking area is at the front of the Hotel. Signage is present on the doors leading out from the Victoria Quays Bar to read: EMERGENCY EXIT ONLY - Please make use of the smoking area at the front of the Hotel. The sign will seek to remind and reinforce to guests and other users that this area is a non-smoking area and that the Hotel's designated smoking area remains at the front of the Hotel; The Hotel has arranged for signage to be placed at the canal side exits highlighting the risk of deep water nearby; The area is well lit and a new CCTV unit on the canal side is to be installed in due course; The LivingWell side entrance/exit is locked after 10:00pm but continues to be in use for gym access and as a designated fire escape route 24 hours a day. The Hotel does not promote this as a general exit or as access to the canal side by way of any signage; The hotel team undertakes regular emergency preparedness training. HILTON SHEFFIELD Victoria Quays j Furniva! Road | Sheffield | S47YA | United Kingdom hilton.com Hilton ¥ Registered OF 32 7PH | Scotland @® Hilto SHEFFIELD As the Assistant Coroner will be aware, the canal towpath is a public right of way with a variety of businesses located in the area as well as the Hotel. The Hotel is a responsible operator and we are not aware of any previous incidents or near misses similar to this tragic case. | do hope that this response provides you with the assurance that action has already been taken to address your concerns. Should you wish for any clarification concerning the Hotel’s actions, please do not hesitate to contact me at the above address. Yours faithfully Hotel Manager HILTON SHEFFIELD rnival Road | Sheffield | S47YA | United Kingdom hilton.com Limited curren’ Scotland
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