Prevention of Future Deaths reports · 2016

Carl Thompson

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 report18 Apr 2016
Reference2016-0492
DeceasedCarl Thompson
CoronerMartin Fleming
Coroner areaWest Yorkshire (West)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

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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