Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0492, written 18 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Apr 2016 |
|---|---|
| Reference | 2016-0492 |
| Deceased | Carl Thompson |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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IN THE WEST YORKSHIRE WESTERN CORONER'S COURT IN THE MATTER OF: The Inquests Touching the Death of Carl Lee Thompson A Regulation Report - Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: LA for Olivia Beach — Carralejo, Fuerteventura (via the Foreign and Commonwealth Office, WH4.8 King Charles Street, London. SWIA 2AH ) 1 | CORONER Martin Fleming, HM Senior Coroner for West Yorkshire Western 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 20 of the Coroners (Investigations) Regulations 2013 3 | INVESTIGATION and INQUEST On 25 August 2015 I opened an inquest into the death of Carl Lee Thompson who, at the date of his death, was aged 36 years. The inquest was resumed and concluded on 23 February 2016. I found that the cause of death to be: - la. Drowning I concluded with a Narrative finding as follows: On 10 August 2015 Carl Lee Thompson died from drowning after being overcome by a rip tide whilst he was bathing in the sea on holiday in Fuerteventura. The life saving equipment was inadequate and in any event the lifeguards were untrained in the use of the equipment, but it remains unclear whether, had the life saving equipment been working and the life guards correctly trained, it would have made a difference to the outcome. RE3S89 1 4 | CIRCUMSTANCES OF THE DEATH On 10 August 2015 at approximately 5.00 pm, Carl Lee Thomson was bathing in the sea with his family in the area of the Hotel Oliva Beach, Corralejo, in the municipality of La Oliva, when they suddenly became overwhelmed by the surf and waves. At the time a yellow flag was being displayed on the beach. Although his family managed to leave the sea safely, Carl found himself overwhelmed such that he was immediately rescued from the sea by the lifeguards and they immediately undertook sustained attempts to resuscitate him, but he succumbed and passed away. The pathologist provided the cause of his death as drowning. 5 | CORONER'S CONCERNS During the course of the inquest I heard evidence to suggest that the life saving equipment used by the life guards was either lacking or defective and there was a substantial delay before the arrival of an ambulance. The MATTER OF CONCERN is as follows. — e The emergency bag did not contain suction equipment to clear the airways e A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen e The defibrillator used during resuscitation was inoperable given it was found to have no batteries e Delay of 45 minutes to obtain a replacement defibrillator e Absence of equipment to dry the casualty e Substantial delay before the arrival of the ambulance and doctor for emergency treatment. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and! would ask you to review the following: - e The effectiveness of the existing life saving equipment and procedures for checking their reliability e The training for lifeguards in the use of the life saving equipment. e The provision of information to holidaymakers in respect of the beach flag warning systems and local hazards of the sea conditions. e The response times for the arrival of emergency ambulances to the location of emergencies I believe that the Local Authority for Corralejo has the power to take RT3589 2 such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 | COPIES I have sent a copy of this report to: e - partner . Thomson Holidays e Manager — Hotel Riu Oliva e UK Consulate for Fuerteventura e Chief Coroner 9 | DATED this 18 April 2016 ju. Prée7 M.D. Fleming Senior Coroner RT3589 3
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