Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0402, written 14 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2016 |
|---|---|
| Reference | 2016-0402 |
| Deceased | Liam Day |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| Category | Other related deaths |
| 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.
Richard Thomas Middleton Assistant Coroner for The County of Dorset REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. British Mountaineering Council 2. Royal Yachting Association CORONER | am Richard Thomas Middleton, Assistant Coroner for The County of Dorset 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 Liam Day Inquest opened on 5/7/16 Inquest heard at Bournemouth on 21/11/16 4 | CIRCUMSTANCES OF THE DEATH Liam was a medical student at Southampton University where he was also a member of the University Moutaineering Club. He left his home address on 15/6/16 to go climbing and failed to return. An extensive search was undertaken along the Dorset coastline following the discovery of a car linked to him and the presence of a climbing rope at Collis Point. The deceased's kit bag was found in this area. The deceased's body was recovered from the water on 28/6/16. The pathologist gave a cause of death as 1a) Hypothermia _b) Falling into the sea. 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. — Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. | found the following preliminary issues contributed to his death:- He was climbing with no safety line He was not wearing a lifejacket or buoyancy aid He was not wearing clothing that offered no warmth in the water He was not on his own He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio He had left no specific instructions as to where he was intending to climb and what time he would be home A PONS 2 The main issue | wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason | am including the RYA in this report. The Coroner's Court, Town Hall, Bourne Avenue, Bournemouth, Dorset, BH2 6DY Tel 01202 310049 | Fax 01202 780423 During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that | wish to highlight. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. | would wish for this case to be circulated to your members to remind those who are already aware of the risks and to inform those ignorant of the same. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27/1/17. |, 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 Person British Mountaineering Council, Royal Yachting Association. | have also sent it x. ho may find it useful or of interest. | 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. Dated 14 December 2016 j Richard T Middleton Assistant Coroner for The\County of Dorset The Coroner's Court, Town Hall, Bourne Avenue, Bournemouth, Dorset, BH2 6DY Tel 01202 310049 | Fax 01202 780423
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.
Mr RT Middleton Assistant Coroner The Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY 19 January 2017 Dear Sir RE: Liam James Day, RTM/02336-2016/U “BMC British Mountaineering Council 177-179 Burton Road, Manchester M20 2BB t 0161 445 6111 f 0161 445 4500 e office@thebme.co.uk w www.thebmc.co.uk Thank you for your letter dated 14 December in relation to the Regulation 28 Report concerning the death of Liam Day. The BMCis the representative body for climbers, hill walkers and mountaineers. A small number of climbers engage in deep water soloing and there is good practice advice about the activity on our website and in climbing guidebooks. The BMC notes all matters of concern within the report relating to Liam, namely that he: was climbing with no safety line was not [sic] on his own Aa PwWNR be home Our thoughts on the above are outlined below. was not wearing a lifejacket or buoyancy aid was not [sic] wearing clothing that offered no warmth in the water had no means of requesting help such as a whistle, a waterproof phone or marine VHF radio had left no specific instructions as to where he was intending to climb and what time he would 1. There is a very long history of roped climbing on Britain’s sea cliffs. Conversely, and by its very nature, deep water soloing is climbing without a rope, with the water being used to absorb the impact of a fall should one be taken. As noted in the report, no trauma was found to Liam’s body. (It is important to note that deep water soloing, where the idea is to complete a climb and so not to fall in the water, is a completely different activity to tombstoning, which involves intentionally jumping into the sea, often from piers and other artificial structures. Tombstoning is not an activity that the BMC represents). 2. Wearing a lifejacket or buoyancy aid whilst climbing would not be practical, and due to its size and weight would likely increase the probability of the climber falling. A buoyancy aid could also present the added risk of neck trauma, as the climber would decelerate faster than if they were not wearing a buoyancy aid. working for climbers, hill walkers & mountaineers Patrons: Sir Chris Bonington CBE, Lord Chorley, Mick Fowler, Lord Greaves, Pat Littlejohn OBE and Doug Scott CBE. Registered in England and Wales a Company Limited by Guarantee N° 2874177. 3. The Regulation 28 Report notes the ‘dangerously low temperatures in coastal waters’ that climbers and others enjoying coastal activities may not be aware of. The BMC shares this concern and will make climbers aware of this serious risk in our guidance, including the phenomenon known as Cold Water Shock. The BMC will also raise this with guidebook writers. 4. ABMC article from 2014 notes one golden rule for deep water soloing, to never go alone. In our updated advice we will ensure that this vital message is brought to the fore. 5. In guidance on our website, the BMC can note the importance for climbers to consider how they may summon assistance when deep water soloing. However, as the golden rule is never to go alone, other members of a climbing party should be in the vicinity to assist another climber. 6. The BMC’s reading of the report suggests to us that Liam telling others of his plans would unfortunately not have saved his life. Whilst not noted in the report, had Liam left a note of his plans his friends and family may have been spared some distress when he did not return, and the rescue services may have been able to focus their search more effectively. The BMC will also highlight this issue in our guidance, suggesting that climbers consider telling others of their plans and their expected return time. This very sad incident has led us to review the guidance we provide, and we will be acting upon the report as noted above. Yours faithfully BMC Deputy CEO
RVA RYA House Ensign Way, Hamble Southampton SO31 4YA United Kingdom Mr RT Middleton Tel +44 (0) 23 8060 4100 Assistant Coroner Fax +44 (0) 23 8060 4299 The Coroner’s Office for the County of Dorset www.rya.org.uk Town Hall Bournemouth BH2 6DY P| 17 January 2017 Dear Sir Liam James DAY — Deceased Thank you for your letter dated 14!" December 2016 enclosing a copy of the Regulation 28 Report in relation to the above. As you know, the RYA is the national body for all forms of recreational and competitive boating under sail or power. It represents dinghy and yacht racing, motor and sail cruising, RIBs and sportsboats, powerboat racing, windsurfing, inland cruising and personal watercraft. We note with interest the matters of concern identified in the Regulation 28 Report. In particular, the Report notes that the deceased was:- e “not wearing a lifejacket or buoyancy aid; e “not wearing clothing that offered no [sic] warmth in the water’; and e “not [sic] on his own”. Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing’, and in fact increase the likelihood of the wearer falling. Within the sports that the RYA represents, the value of wearing a lifejacket or buoyancy aid and appropriate clothing is reasonably widely recognised. Nevertheless, the RYA has recently refreshed the safety information pages on _ its website (www.rya.org.uk/go/safety) and cold water shock appears prominently on the first page (under “look after yourself’). The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA’s annual Safety Advisory Notice. Yours faithfully, Director of External Affairs Patron Her Majesty The Queen President HRH The Princess Royal KG, KT, GCVO, QSO Chief Executive Sarah Treseder Royal Yachting Association is a company limited by guarantee and registered in England. Number 878357
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