Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0410, written 16 Nov 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 Nov 2017 |
|---|---|
| Reference | 2017-0410 |
| Deceased | Anthony Grant |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
Anthony Cleon GRANT (died 19.08.16)
THIS REPORT IS BEING SENT TO:
1.
Director
Royal Life Saving Society UK
Red Hill House
227 London Road
Worcester WR5 2JG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 25 August 2016, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of Anthony Cleon Grant,
aged 56 years. The investigation concluded at the end of the inquest on
19 October 2017.
The jury made a narrative determination at inquest, which I attach. I
apologise for the delay in the making of this report, brought about
because I have been making further enquiries.
4
CIRCUMSTANCES OF THE DEATH
Mr Grant was swimming in the public pool at Mile End Leisure Centre
(managed by Greenwich Leisure Limited) when he suffered a cardiac
event and drifted to the bottom of the pool.
1
A member of the public noticed him and alerted the lifeguard, who
performed an emergency rescue. Lifeguards gave cardiopulmonary
resuscitation, but this was not successful and Mr Grant died on poolside.
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.
Mr Grant drifted under the water and remained submerged for five
minutes and 41 seconds before a member of the public noticed him and
alerted a lifeguard. The lifeguard had been on duty on poolside
throughout.
Quite apart from the actions of an individual lifeguard, there are many
ways that pool safety could have been approached differently that day.
The lifeguards could have changed position after half an hour or an hour
as had been intended. There could have been more than one lifeguard
on poolside. The lifeguards could have been supported by a motion early
warning system. These are all matters for the industry to explore.
I write to you specifically because Mr Grant’s family have given their
consent for me to forward to you the footage of the pool CCTV from the
time when he first got into difficulty to the end of the attempted rescue,
in the hope that you will be able to make this, or at least part of this,
nationally available as a training tool.
This is obviously an incredibly generous act on the part of Mr Grant’s
family, but I imagine that they would prefer Mr Grant’s name not to be
used when showing the video, particularly as some of his children are
still minors.
I am aware that your organisation has already made training DVDs, but
it seems to me that there is something uniquely powerful in lifeguards in
training being given the opportunity to watch real events such as those
on this clip. It provides the most vivid reminder possible of the need for
constant vigilance on poolside.
Once seen, this is a piece of film unlikely to be forgotten, and Mr Grant’s
family hope it can be used to save other lives.
6
ACTION SHOULD BE TAKEN
2
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 15 January 2018. 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
, daughter of Anthony Grant
, managing director, Greenwich Leisure Limited
Chartered Institute for Management of Sport and Physical Activity
UK Active
I 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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
16.11.17
3
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.
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 10th January 2018 RE: Regulation 28: Prevention of Future Deaths Report – Mr. Anthony Cleon Grant Dear Ms. Hassell I am writing to you in reply to the Regulation 28: Prevention of Future Deaths Report regarding Mr. Anthony Cleon Grant who sadly passed away on the 19th August 2016. Once again, I would like to pass on my condolences to Mr. Grant’s family and those that knew him at this very difficult time. I am writing to you specifically to request an extension to the time to formally respond to your FDR and I would like to explain the reasons for this request. I have taken the time to listen to the court recording to better understand the background to the case. On receipt of your FDR I have been seeking to work in co-operation with the organisations listed in the report in order that collectively we could respond in the most appropriate way. I am pleased to say that Greenwich Leisure Limited, the Chartered Institute for Sport and Physical Activity (CIMSPA) and ukactive have all supported to work in a cooperative manner in order that swimming pool safety matters can be improved where appropriate. Unfortunately, it has only been last week when it has been possible to meet as a collective to discuss the possible and practical action that could be achieved to prevent future deaths. At our meeting on the 9th January we discussed options that were available. However, it was noted that Greenwich Leisure Limited and the Lifeguard on duty on 19th August 2016 may be subject to criminal charges because of the incident. I am conscious that any proposed action the Royal Life Saving Society take could prejudice any outcome of any criminal charges or indeed civil claims and I would be grateful if an extension could be granted until such time that the legal proceedings have progressed further. The Royal Life Saving Society and our partners are committed to raising the standards of swimming pool safety and the performance of lifeguards. To support this further we are considering the creation of a further DVD to support such matters although we have reservations about using real life footage where legal proceedings are currently ongoing. In addition, I would welcome additional time to review what impact the use of real life footage would have on those staff (and colleagues) that were involved on the day and on the future recruitment of lifeguards to the wider leisure industry. In our previous two training DVDs we have, in most instances, used footage from fictitious swimming pool scenarios to stress the importance of lifeguard vigilance, combined with real life interviews. This has proved to be Registered Office: RLSS UK, Red Hill House, 227 London Road, Worcester, WR5 2JG T: 0300 3230 096 | E: info@rlss.org.uk | rlss.org.uk Company Limited by Guarantee Registered Charity Numbers: 1046060 / SC037912 Registered in England and Wales: 3033781 VAT Registration Number: 754 5285 12 successful in reminding lifeguards of the important role that they play and it would be this format that we would have preference towards in this instance. However, we discussed that there is an imminent opportunity to raise important swimming pool safety matters that are detailed within the FDR, notably those issues concerning lifeguard numbers, lifeguard rotation and drowning detection systems. On the 21st February 2018, CIMSPA are hosting their annual conference and this event will host the launch of the Health and Safety Executive revised guidance, Managing Health and Safety in Swimming Pools (HSG 179). As a representative of the Royal Life Saving Society UK I have the opportunity to speak about the revised guidance and will raise the important issues highlighted in your report. The Royal Life Saving Society UK, CIMSPA and ukactive are also committed to providing a summary of the changes between the current and new versions of Managing Health and Safety in Swimming Pools. It is intended, alongside the summary, that we include clear reminders about the importance of lifeguard vigilance and about the roles that operators play in terms of safety within swimming pools. Within this publication, it is intended that we raise the issues highlighted in the FDR. Prior to the FDR, the Royal Life Saving Society have been committed to creating a supervisory qualification that is aimed at Duty Managers. An aim of the qualification is to remind those that are supervising lifeguards of their responsibilities to prevent accidents. This will include information that you have highlighted in the FDR. It is intended that this qualification is launched in the first quarter of 2018. In summary, considering the ongoing criminal proceedings I would welcome an extension for a period of three months before formally replying specifically on the matter of the training DVD. Your sincerely Martin Symcox Director RLSS UK Registered Office: RLSS UK, Red Hill House, 227 London Road, Worcester, WR5 2JG T: 0300 3230 096 | E: info@rlss.org.uk | rlss.org.uk Company Limited by Guarantee Registered Charity Numbers: 1046060 / SC037912 Registered in England and Wales: 3033781 VAT Registration Number: 754 5285 12
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