Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0465, written 28 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 | 28 Dec 2016 |
|---|---|
| Reference | 2016-0465 |
| Deceased | Simon Charles |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Re SIMON DENNIS CHARLES REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ft Director of South West National Trust, Broadclyst, Exeter, Devon, EX5 3LE CORONER | am the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly 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. INVESTIGATION and INQUEST On 5"" July | commenced an investigation into the death of SIMON DENNIS CHARLES, then aged 49. The investigation concluded at the end of the inquest on 13" December 2016. The conclusion of the inquest was an Open Conclusion, the medical cause of death being massive head and chest injuries. CIRCUMSTANCES OF THE DEATH Simon Charles was found dead at the foot of cliffs at Hells Mouth, Gwithian, Hayle at around 5.50 am on 3° July 2016 after a concern for welfare search for him. He was found floating in the sea and was brought ashore by the lifeboat at St Ives where a paramedic recognized him dead formally at 7.29am. His locked van was found in the Hells Mouth car park at around 11.00 pm the evening before. He was last known to be alive at around 6.00 pm on 2nd July when he left his home address i No suicide note was found but Hells Mouth is a known suicide location. He was suffering from depression and made a serious attempt to take his own life on 14" June 2016 by overdose. He was supported by the mental health team and emergency help numbers were provided to him. Although everything pointed to his death being a suicide, the legal level of sure could not be established as due to lack of evidence an accidental fall could not be excluded. 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. — The Family and others at inquest raised concerns that there are not more preventative measures (apart from a fence) to those contemplating suicide (or undertaking risky behaviour) at Hells Mouth, which is a renowned suicide location in Cornwall. They provided examples of the type of measures which they felt could additionally be put in place such as: e Providing the telephone number of suicide support agencies such as the Samaritans in the same way as at Beachy Head, East Sussex e Using natural barriers at the edge of the cliff such as encouraging or planting gorse or other such plants as in Devon along the coast line especially where falls have been known to have occurred The coastline around Cornwall and in particular, the area around Hells Mouth are owned by the National Trust. It would require the consent of the National Trust to put up such signs or other preventative measures and this is the reason for raising the concerns with you and your organisation. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action and to work with other partnership agencies such as the Samaritans, Public Health and Cornwall Mental Health Services to review what extra preventative measures could be put in place. | have sent a copy of this letter to these organisations so that they are aware of the concerns raised at the inquest. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 23° February 2017. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the follgwi Persons; as) HE (family) and Medical Director of Cornwall Partnership Foundation Trust. | have also sent it to Consultant in Public Health and Director of the Cornwall Samaritans who 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. [DATE] [SIGNED BY CORONER] 28/12/2016 Crrgalttty Ere Cllyon
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.
National 18 January 2017 Trust Dr E E Carlyon Senior Coroner for the County of Cornwall Coroner for Cornwall and Isles of Scilly The New Lodge Newquay Road Penmount Truro TR4 9AA Dear Dr Carlyon Thank you for your letter dated 28" December 2016 regarding the recent inquest into the death of Simon Dennis Charles. | can confirm that our local team are in contact with aa Director of Cornwall Samaritans, to investigate options for introducing signage at Hells Mouth. The initial thought from our staff is that it would be most practical to have small signs on the barrier near the cliff edge and potentially larger signs in the car park of the café opposite (where Mr Charles’ parked van was found). The latter would require the agreement of the café owners. We anticipate we will be able to have the signs installed on our own land before the Easter Bank Holiday in April. With regards to the suggestion that vegetation could be planted to prevent access to the cliff edge, we believe this would be difficult to achieve and counterproductive. The exposed nature of the cliff top in this area limits the natural growth of shrubs and we feel it would not be possible to establish sufficient growth to prevent physical access to the cliff. The impact on the views that screening by vegetation would produce would, in our view, encourage visitors to circumvent such a barrier and put themselves in a potentially much more dangerous position, leading to a greater chance of accidental trips and falls. National Trust President: HRH The Prince of Wales South West Region Regional Chair: Killerton House, Broadclyst Regional Director: Exeter, Devon EX5 3LE Tel: +44 (0)1392 881691 Registered office: www.nationaltrust.org.uk Heelis, Kemble Drive, Swindon, Wiltshire SN2 2NA Registered charity number 205846 Should you wish to, our local ranger team would be happy to meet on site to discuss any other practical measures that may be suggested. If this is something which you would like to do please contact the General Manager for South and Mid Cornwall, Bill Makin, on 01208 265228 who would be happy to set up a meeting. Yours sincerely Director for the South West
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