Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0275, written 16 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Aug 2017 |
|---|---|
| Reference | 2017-0275 |
| Deceased | Spencer Hurst |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Parkhill Group of Companies, Fernhill offices, Sutton Newport, Shropshire TF10 8DJ 2. Chief Executive- Walsall Metropolitan Borough Council 3. Chief Coroner 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 the 21 June 2017, I commenced an investigation into the death of the late Spencer Lloyd Hurst. I held a pre-inquest review hearing on the 9 August 2017. The resumed inquest is scheduled to take place on 18 September 2017 at the Black Country Coroner’s Court. The provisional cause of death is: 1a Drowning 4 CIRCUMSTANCES OF THE DEATH i) On the evening of the 20 June 2017, a 15 year old male, Spencer Hurst was with a group of his friends that went into a lake on private land in Ryders Hay Lane, Pelsall. ii) The lake is locally known as Ryders Hayes Mere and is described as a flooded open cast coal pit and contains a small island. iii) It appears the group were swimming together when Spencer has got into trouble and went below the surface of the water. Despite assistance from his friends they were unable to locate him. iv) Sadly his body was recovered by the emergency services a short time later and he was pronounced deceased. 5 CORONER’S CONCERNS During the course of the investigation and pre-inquest hearing review, matters giving rise to concern were noted. 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. Evidence emerged during the investigation and pre-inquest hearing review that 1 [IL1: PROTECT] another young male had died in very similar circumstances at the same location on the 11 June 2007. 2. Despite this being the second death, evidence emerged that there have been no adequate notices displayed to warn of the risks of swimming in the lake and no evidence of any fencing or appropriate measures taken to mitigate the risks. 6 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. 1. You may wish to consider as a matter of urgency implementing measures to try and prevent or deter swimmers in the lake by restricting access or providing monitoring of the site. 2. The responsible local authority has also been notified to offer appropriate advice or consider any relevant action that needs to be taken. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 October 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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 16 August 2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Inquest into the death of Spencer Hurst ______________________________________________________________________ Regulation 28: Report to Prevent Future Deaths Response on behalf of Parkhill Estates Limited, Fernhill Offices, Sutton, Newport, Shropshire, TF10 8DJ Background The Senior Coroner for the Black Country issued a Regulation 28 Report on 16 August 2017 in relation to the investigation into the death of Spencer Hurst (“the Reg 28 Report”). Spencer Hurst sadly passed away on 20 June 2017 when he was swimming in the mere situated at Ryders Hayes in Walsall (“the Mere”). This response to the Reg 28 Report is prepared on behalf of Parkhill Estates Limited (“Parkhill”) and Parkhill would at the outset like to express again its sincere condolences to Spencer’s family and friends for their loss. The Reg 28 Report was issued by the Senior Coroner prior to the Inquest which took place on 18 September 2017. This response has therefore been prepared taking into account the Reg 28 Report, the evidence that was heard at the Inquest and the various discussions that have taken place between the Interested Persons. The Mere Parkhill is the owner of the Mere and the area of land surrounding it and we provide here, so that this response can be read in context, a very brief introduction to the background and development of the Mere. In 1999, Parkhill commenced restoration works to the land in question which included the construction of the man-made Mere which has a surface area of around 6.8 hectares including the islands situated in the centre. There are no sudden changes in depth beneath the surface and the sides of the Mere were designed to be on a gradual gradient. The design and build of the Mere was carefully considered and risk assessed, including by independent experts, and it was approved by the relevant Local Authority, Wallsall Metropolitan Borough Council (“WMBC”). Risk assessment at the design stage suggested that signage and fencing would be ineffective to prevent or deter swimmers in the Mere and the grading of the Mere edges was therefore Parkhill Response to Regulation 28 Report designed in to prevent anybody accessing the deeper water by mistake or without making a deliberate effort to do so, and to get back to shallow water easily. The planting and landscaping of the land immediately adjacent to the Mere was also designed to ensure anyone entering the water could get out without impediment. Previous attempts by Parkhill to secure a permanent presence on the land have been rejected by the Planning Department of WMBC. The Senior Coroner’s Concerns During the course of the Senior Coroner’s investigation, prior to the Inquest, matters giving rise to concern were noted. In the Senior Coroner’s opinion, on the basis of the information he had gathered at that stage, there was a potential risk that future deaths might occur unless action was taken. The possible actions that the Senior Coroner canvassed in the Reg 28 Report were: 1. You [Parkhill] may wish to consider as a matter of urgency implementing measures to try and prevent or deter swimmers in the lake by restricting access or providing monitoring of the site. 2. The responsible local authority has also been notified to offer appropriate advice or to consider any relevant action that needs to be taken. The Response Parkhill takes matters of safety very seriously and the company acted immediately upon receipt of the Reg 28 Report from the Coroner’s office. Parkhill made attempts straightaway to contact the relevant local authority, WMBC, with a view to organising a meeting with the appropriate persons there to discuss what might be done to deter swimmers at the Mere and to obtain advice from WMBC in line with the Reg 28 Report. Parkhill engaged in discussion with WMBC regarding how the issue of persons swimming in the Mere, and the dangers of open water, might be best addressed taking into account, among other things: (1) the features of the Mere including the control measures that had been designed into the Mere’s construction; (2) Parkhill and WMBC’s experience with the Mere over the last 18 years since its construction; and, (3) WMBC’s long experience of assessing and dealing with other meres/lakes in the Borough. WMBC informed Parkhill (as per the reports and statements prepared by its employees for the Inquest and in line with the live evidence given at the Inquest) that they do not consider that signage or fencing at Ryders Hayes Mere would be effective to prevent or deter swimmers. 2 Parkhill Response to Regulation 28 Report It is also Parkhill’s experience that signage has not been effective at this location in the past. Both Parkhill and WMBC have, historically and at different times, placed signage and/or buoys around the Mere. However any signage or other apparatus was destroyed and/or taken down very quickly and in some cases (on the evidence of WMBC) within a matter of hours of being erected. Parkhill understands that WMBC is of the view that the best way to prevent or to deter unsafe swimming in open water is by teaching young people about the dangers of it and encouraging young people to learn to swim. WMBC is currently undertaking a campaign in the local area to provide positive preventative workshops to young people on this issue which is an approach that Parkhill agrees with and supports. To try an overcome the issues and difficulties experienced by Parkhill and WMBC with regards to signage at the Mere being removed or destroyed, Parkhill has, since the Inquest, engaged in discussion with the family of Spencer Hurst regarding the possibility of erecting signage which also incorporates a memorial to Spencer. The hope is that a memorial may act as a deterrent to other young persons who might go to the Mere and would be less likely than ordinary signage to be vandalised or removed. Spencer’s mother has kindly indicated that she would be agreeable to a memorial being implemented as a control measure at the Mere in the hope that it may deter swimmers. Parkhill has commissioned a large piece of rough-hewn sandstone to be prepared which will stand on the foot path adjacent to the Mere with both sides of the stone clearly visible. The sandstone will be concreted in (below ground level) so it cannot be tipped or pushed over and will stand 4 – 5ft high so that it can be clearly seen by those accessing the Mere’s edge. The wording that will be carved on one side, which has been agreed by Spencer’s family, is “In loving memory of Spencer Hurst (Champ) forever in our hearts missed and loved always RIP”. On the other side, the stone will be carved with the message “Please be aware that swimming in open water is extremely dangerous”. In addition to the sandstone memorial at the Mere side, Parkhill has commissioned the preparation of four signs to be erected at the four natural entrances to the Mere. Those signs will reinforce the safety message “Please be aware that swimming in open water is extremely dangerous” using similar font to that used on the memorial in the hope that the messages on the entrance signage are also respected by local visitors to the land. Since the Inquest the Company has been liaising with local stone masons with a view to sourcing a suitable piece of rock to form the memorial. All is progressing well with the erection of the memorial/signage and it is anticipated that it will be in place by the spring 2018 in time for the summer season when there will be increased visitors to the land around the Mere. Once the signage is established on site, Parkhill will organise and implement a 6 monthly inspection regime of the signage. Following each inspection the Company will conduct an assessment to decide if any further actions are required in respect of the signage at Ryders Hill Mere. 3 Parkhill Response to Regulation 28 Report Conclusion It is hoped that the measures outlined in this document, along with the evidence heard at the Inquest, satisfy the concerns that the Senior Coroner had prior to the Inquest. Parkhill would be happy and willing to assist with any further queries that the Senior Coroner might have in relation to the Mere or any other matter. Parkhill Estates Limited 9 November 2017 4
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