Prevention of Future Deaths reports · 2016

Alfie Gray

Regulation 28 report to prevent future deaths, reference 2016-0262, written 25 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report25 Jul 2016
Reference2016-0262
DeceasedAlfie Gray
CoronerPenelope Schofield
Coroner areaWest Sussex
CategoryChild Death (from 2015) · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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: 

Association of British Travel Agents 

1 

CORONER 

I am Penelope Schofield, Senior Coroner, for the area of West Sussex 

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 4th March 2016 I concluded the inquest into the death of Alfie Wayne Eddie Gray born 2nd November 
2007 (aged 7 years), who died on 7 July 2015. I determined that Alfie Gray had died an accidental death 
having drowned. 

4 

CIRCUMSTANCES OF THE DEATH 

On 6th July 2015 Alfie Gray and his family travelled to Sharm El Sheikh, Egypt along with another family..  
They  stayed  at  the  Reef  Oasis  Beach  Resort.    The  holiday  had  been  organised  by  the  Global  Travel 
Group. 

On 7th July 2015 Alfie was playing in the pool at the hotel resort along with other family members.  The 
pool had a waterfall coming into it.  The pool should have been monitored by lifeguards. Just after lunch 
Alfie’s mum left the pool side to collect a bottle for her baby and when she returned she noticed that Alfie 
was missing.  

Staff at the resort did not take the incident seriously and it was left for family and other holiday makers to 
search for Alfie. Sadly he is found at the bottom of the pool under the waterfall.  The time between the 
family  realising  that  he  was  missing  and  Alfie  being  found  was  around  45  mins.    It  was  clear  from  the 
evidence that had he been found sooner he may well have been able to have been resuscitated. 
CORONER’S CONCERNS 

5 

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)  The  provision  of  lifeguards.  It  appeared  that  the  number  of  lifeguards  on  duty  at  this  resort 
were inadequate. The life guards did not have any medical training and communication with the 
holiday makers proved difficult when help was needed.  

(2)  The lifeguards went off duty for an hour over lunchtime.  This information was not communicated 

to the family either by the hotel or the travel company. 

I consider that the issues raised in this case have much wider implications which should be addressed by 
Travel Companies so that future deaths do not occur in similar circumstances and that action should be 

5981872.1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 taken to reduce the risk of deaths. 

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 by addressing this issue with your members. 
YOUR RESPONSE 

7 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th 
September 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

1. 
2.  Global Travel Group 

 parents of the deceased. 

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 

DATE:     25th July 2016                                          SIGNED: Penelope Schofield, Senior Coroner,  
West Sussex 

1 

5981872.1

Responses

1 response 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.

Response from Abta (PDF)
Ms P. Schofield, 
Senior Coroner, 
West Sussex, 
Coroner’s Office, 
Orchard Street, 
Chichester, 
West Sussex PO19 1DD.  

Dear Ms Schofield 

15 September 2016 

Thank you for your letter in regard to the sad death of Alfie Gray. We write in response to your letter 
and Regulations 28 and 29 of the Coroners Regulations 2013. We have been carefully reviewing the 
report and your requests for action.  

I thought it would be helpful to firstly outline the purpose and role of ABTA. We are a trade 
association representing and providing services to our Members who make up a significant part of 
the UK travel industry and who sell a range of travel services including package holidays, flights, 
accommodation and car hire. ABTA provides services to consumers through its consumer affairs and 
arbitration services which deal with a range of consumer issues involving ABTA members. 

ABTA also fulfils a regulatory role in respect of its members through its Code of Conduct and 
financial protection function. In regard to health and safety, ABTA provides guidance to Members 
and raises awareness on key safety issues with consumers and destination authorities. I should 
highlight that Global Travel Group are not an ABTA Member therefore would not generally have 
access to the advice and guidance we provide to Members on health and safety.  

In regard to our Members, we believe they view their customers’ welfare as a priority in their 
assessments and programmes. However each ABTA member will contract properties very 
differently, from solus use of the entire property to ad-hoc allocations of rooms per year. Members 
make their own decisions about their programmes including the choice of properties and whether 
and how they decide to audit these properties from a health and safety or sustainability perspective 
based on their contractual arrangements with the property.  

In the absence of European-wide standards or a directive on tourism accommodation safety UK tour 
operators came together, originally as the Federation of Tour Operators (FTO), to develop the 
Tourism Accommodation Health and Safety Technical Guide best practice guidelines (the Technical 
Guide). The first edition of the Technical Guide was developed in 2000/1 and the current edition (3) 
in 2012 as ABTA/FTO. The guidance enables tour operators to have a common approach to suppliers 
on a non-competitive issue such as safety. The guidance covers key health, safety and security issues 
for accommodation suppliers. Each chapter has been consulted on and developed with experts in 
their field. The Technical Guide is reviewed every few years, and it is currently being reviewed by 
Consultants who are experts on the different safety aspects, the guidance is updated to reflect any 
new evidence based safety changes.  

I address your request in Section 5 in regard to the matters of concern. You draw attention to the 
provision of lifeguards, medical training and communications. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -2- 

The presence of lifeguards at swimming pools is not a legal requirement in many overseas countries, 
nor is it in the UK. The current Technical Guide section on Pool Safety and Waterparks addresses the 
subject of lifeguards. In the Customer Information section there are clear recommendations on the 
need to inform customers as to whether there is a lifeguard present or not.  

We believe this advice is important for any property that has swimming pools as research shows that 
British nationals of all ages have experienced difficulties when swimming in the UK and overseas. In 
the absence of international standards on the requirement for lifeguards we believe that the 
Technical Guide does reflect current best practice and helps to create a common approach.  

In addition to the Technical Guide we also have an ongoing campaign with the Royal Life Saving 
Society and the Foreign and Commonwealth Office to raise awareness about the potential risks of 
swimming on holiday and to raise awareness about building up swimming ability prior to a holiday. I 
attach a copy of the posters and key messages. 

 The Technical Guide section on Pool Safety addresses emergency procedures from management 
responsibility to appropriate staff training. The Management Responsibility section addresses the 
need to train staff in lifesaving techniques, CPR and first aid. We believe that this reflects current 
best practice and we continue to promote this approach for Members to their suppliers.  

We have drawn your Matters of Concern to the attention of the Consultants currently reviewing the 
relevant sections of the Technical Guide. We do know that there has already been discussion about 
and a review of the information on emergency procedures and the signage at swimming pools. Any 
new guidance on these matters will be built in to the next edition of the Technical Guide. 

I would also highlight that ABTA and our members have been calling for a European Tourism 
Accommodation Safety Directive to create a common framework for all travel across Europe. Whilst 
this would not cover global safety standards we have seen that where European Standards are 
developed these can get adopted in other key tourism destinations. I include a summary of our 
Tourism Accommodation Safety campaign activity. This is a core part of our policy agenda and we 
continue to lobby for change.  

ABTA is not aware of the full facts in the specific case which is the subject of your report and 
therefore is unable to comment on the particular circumstances surrounding the tragic death. We 
wish to offer our sincere condolences, through your office, to the family and friends of Alfie Gray.  

Yours sincerely, 

Mark Tanzer  
Chief Executive 

Encs.

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