Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0202, written 27 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 May 2016 |
|---|---|
| Reference | 2016-0202 |
| Deceased | Keenan Walsh |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter and Greater Devon |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. The County Solicitor Devon County Council Room G26 County Hall Topsham Road Exeter 2. The Managing Director North Devon Council PO Box 379 Barnstaple EX32 2GR 1 | CORONER | am Dr Elizabeth Ann Earland, Senior Coroner for the coroner area of Exeter and Greater Devon. 2 | 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. 3 | INVESTIGATION and INQUEST 7 On 16 September 2013 | commenced an investigation into the death of Keenan John WALSH, aged 4 years. The investigation concluded at the end of the Inquest on Wednesday 25 May 2016. The conclusion of the Inquest was a Narrative Conclusion, details as follows: “Keenan, a non-swimmer, died as a result of a tragic drowning accident in the 9 foot deep end of a heated swimming pool at Bicclescombe Grace, Kingsley Avenue, Ifracombe, whilst attending a large family party. Sometime between 17:45 hours and 18:17 hours 23 August 2013, Keenan submerged in the deep end of the pool whilst inadequately supervised in company of a permutation of 42 children jumping in and out and two adults, neither of whom were available to rescue him. The slope of the deep end was a factor. Vision was obscured by large numbers of inflatables. Immediate attempts at resuscitation and subsequent transfer to North Devon District Hospital, then Paediatric Intensive Care Unit at Bristol Children’s Hospital, failed to avert his subsequent death from la. Complications of near-drowning.” 4 | CIRCUMSTANCES OF THE DEATH See 3 above. 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. — (1) At the time of the incident private holiday lets with swimming pools were not regulated by the Health and Safety Department of Local Authority Environmental Health, despitg o“ ve a aa ei part of local economy. See recording of evidence of Environmental Health Officer (North Devon Council). (2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented a significant hazard to non- swimmers approaching a sharp slope to the deep end. (3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident. This ratio was against the advice of the proprietors but unenforceable. Responsibility lay with adult family members. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you your organisation have the power to take such action. | refer you to the advice received in Evidence from EEE Environmental Health Officer in her report. . “Pool Profile The gradient of the swimming pool in water depths of 1.5m and 1.35m had been calculated as approximately 1 in 3.7. This means that the pool does not comply with either the new European Standard BS EN 15288-2.2008 or the standard outlined in HSG 479 these being 1 in 10 and 1 in 15 respectively. The Officers have strongly recommended that the owners consider re-profiling the floor of the pool to a gradient which meets the requirements of those standards. In the meantime Officers recommended that: a) a diagram showing pool depth and profile should be displayed poolside. b) The sides of the pool should be clearly marked at areas of steep gradient with signs erected warning of the sudden change in depth. c) To consider the possibility of introducing a physical barrier between the changes of water depth. This could include the provision of floating buoys, for example. d) Consider clearly marking the areas of steep gradient with coloured pool tank markings. ° Signage a) Clear, water depth signs should be provided which are clearly visible to the bathers, when they are both on the pool surrounds and in the water. 2 b) Signs indicating general ‘do’s’ and ‘don'ts’ should be placed prominently poolside. Warning signs such as ‘No Diving’, etc., should be displayed in a pictorial format to comply with the Health & Safety (Safety Signs & Signals) Regulations 1996. ° Access to Pool a) A high handle, ‘out of reach’ of younger children should be provided on the main entrance door to the poo! hall. b) Access to the pool hall is located close to deep water. Bathers may enter the water at the first entry point without checking that the water depth is appropriate — a articular problem for children and inexperienced swimmers. EEE sugested that a physical barrier such as a guard-rail could be provided. Under the circumstances we would agree that a guard-rail and warning signs would be appropriate.” Further to this she stated in Evidence that it had recently been decided by the Legal Department that such holiday lets would fall to be included with the provisions of Section 3 Health and Safety at Work Act 1974 (the proprietors being self-employed). If this is so | invite you to clarify this point with all involved in the tourist industry in the county and take such action as is felt necessary. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 July 2016. 1, the Senior 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 Persons, who may find it useful or of interest. FP (Father of Deceased) EE Mother of Deceased) | 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. mB & Dr Elizabeth A. Earland HM Senior Coroner Dated this 27" day of May 2016
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.
County Council : County Solicitor HM Senior Coroner for the County of Devon Legal Services & Communications Exeter and Greater Devon District . County Hall Room 226 Topsham Road Devon County Hall Exeter Topsham Road EX2 4QD Exeter DX 744970 Exeter 31 Fax: 01392 382286 Our Ref: Your Ref: P| 22 July 2016 Dear Dr Earland Re: Regulation 28 Report into the death of Kennan John WALSH ~ DOD 24.08.2013 Inquest 23 — 25 May 2016 We write further to your Regulation 28 Report sent on’27 May 2016, your letter of 20 June 2016 and your letter of 4 July 2016. You helpfully explained that the purpose of a Regulation 28 Report is to identify those authorities who have the power to make changes to improve practice which may prevent further deaths and to bring the relevant circumstances to their attention. We note the content of North Devon Council’s response and agree with them that the responsibility for enforcing health and safety in holiday lets sits with District Councils across Devon. In light of this Devon County Council has no power to make changes to improve practice as that power is in the hands of the District Councils. Devon County Council no jonger undertakes tourism operational activities as these are in the process of being transferred out to the ‘Visit Devon Community Interest Company’ however, Devon County Council shall raise the issue with this organisation so that it may raise awareness of the issue across Devon. For the County Solicitor
Report to Dr Elizabeth A Earland H.M. Senior Coroner North Devon Council’s response to your Regulation 28 Report to prevent future deaths. Keenan John WALSH Deceased Inquest: 23 - 25 May 2016, Devon County Hall, Topsham Road, Exeter North Devon Council’s (NDC) responsibilities for enforcing health and safety. NDC is an authority responsible for enforcing health and safety by virtue of $18 Health and Safety at Work etc Act 1974. The Health and Safety (Enforcing Authority) Regulations 1998 allocate responsibility for the enforcement of health and safety in holiday lets to local authorities where temporary or permanent accommodation is provided for more than 20 weeks. In May 2013 HSE published the National Local Authority Enforcement Code (the Code). The Code was developed in response to the recommendation in “Reclaiming health and safety for all: an independent review of health and safety legislation” by Professor Ragnar Léfstedt for HSE to be given a stronger role in directing Local Authority (LA) health and safety inspection and enforcement activity and as an outcome of the Red Tape Challenge on health and safety. The Code is designed to ensure that LA health and safety regulators take a more consistent and proportionate approach to their regulatory interventions. It sets out the Government expectations of a risk based approach to targeting. In May 2016 the HSE issued Local Authority Circular (LAC 67/2 (rev 5)) to provide guidance and tools for priority planning and targeting these interventions to enable them to meet the requirements of the Enforcement Code. The LAC identifies 10 activities/sectors where it is appropriate for local authorities to carry out proactive inspections. These are based on national priorities. This list does not include managing safety in swimming pools. The LAC also allows for the development of local intervention plans which are based on a regional/district needs assessment. For a number of years swimming pool safety has been identified as a local priority in NDC’s intervention plan. NDC’s performance in enforcing swimming pool safety NDC’s performance in relation to the proactive inspection of swimming pools is set out in Appendix 1. While there are no swimming pool specific health and safety laws, officers require operators to comply with the general duties under the HSWA 74 and associated regulations. Officers refer to and promote the guidance, issued by the HSE entitled ‘Managing health and safety in swimming pools’. This is available at www.hse.gov.uk/pubns/books/hsq179.htm There is no requirement to register/licence a swimming pool and this makes it more challenging for regulators such as NDC to maintain an up to date data base. NDC’s enforcement of health and safety at Bicclescombe Grange, Score View, Ilfracombe, EX34 8ET. The operator has complied with the works the investigating officer set out in relation to health and safety contraventions regarding signage and access to the swimming pool. The operator has given a commitment to re profile the pool before the end of September 2016. This control was set out as a recommendation. The Council is seeking counsel's opinion so that it can better advise its enforcement officers on the scope of $3(2) Health and Safety at Work etc Act 1974 (duties of self employed persons to persons other than their employees). This opinion will be shared with the other local enforcing authorities in Devon via the Chief Environmental Health Officers Health and Safety Sub Group. This will inform the development of all Local Authority intervention plans across Devon and the tourist industry in the county will be advised accordingly. Summary NDC will continue to invest resources in enforcing swimming pool safety, this is a local priority. NDC will share the outcome of this inquest and counsel’s opinion with other health and safety local authority regulators in Devon, with a view to enhancing the effectiveness and consistency of all local authority intervention plans,in the region. Mike Mansell Chief Executive North Devon Council 28th June 2016
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