Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0020, written 18 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2018 |
|---|---|
| Reference | 2018-0020 |
| Deceased | Abdul-Jamal Ottun |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| 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 THIS REPORT IS BEING SENT TO: 1, The Rt. Hon Damian Hinds, Secretary of State for Education, 145-157 St. John St, London EC1V 4PY CORONER Iam Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST On 15th December 2016, I opened an inquest into the death of Master Abdul-Jamal Ottun, who died on 12.07.15 (01962-15) (JW) in British Columbia, Canada. The delay in holding the inquest was due to difficulties in securing disclosure from the police investigation, which necessitated an application in a higher court in Canada. It was concluded on 15th December 2017. The medical cause of death was 1a Drowning The Conclusion of the Coroner was Accident. CIRCUMSTANCES OF THE DEATH The circumstances of death were recorded as follows: Master Jamal Ottun was a 17 year old school student who arrived on a school rugby tour in British Columbia, Canada, on 11th July 2015. On the 12th July, he was in a group of students who went swimming in Shawnigan Lake. His absence was noted a short time after he entered the water and searching began almost immediately. They were hampered by poor visibility underwater. He was found by emergency services about 15 minutes after going missing. Advanced life support was stopped after 40 minutes at about 17:35 hours. Autopsy confirmed he had drowned. This was due to his not being a strong swimmer and being unacclimatised to the cold water (about 16 ° at the surface) which risks were not known to the trip leader. He either had cold water shock or cramp, or both, which rendered him immobile. He did not struggle and his plight was not spotted by his teachers or peers in the water, nor by a volunteer supervisor who was taking photographs from the jetty. Entering the water from the jetty rather than a tarmac beach also contributed to his death. CORONER’S CONCERNS During the course of the inquest, the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. - Evidence was heard from an exper who has worked in water accident prevention for many years and is currently educational advisor for 36 schools. He reported that 50 children drown in the UK annually and the rate is particularly high in the teenage years, because of ignorance of dangers and bravado and peer pressure. He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. He said that in this country schools do not teach children to swim to a sufficiently high standard to be safe. Children are often expected to swim 25m ina heated pool, which gives no skills to save oneself in deep cold open waters, This compares with New Zealand, where 400m is the target used in education. Swimming is not in British schools’ curricula: there is no requirement for any swimming at secondary school and access to pools is limited. He said that child deaths will continue to occur unless there is a fundamental change in the curriculum and in the pre-assessment of swimming ability before school trips and occasions when swimming outdoors. In this case, parents indicated on a form the swimming ability of their children in one of three boxes (strong/ moderate/ weak) This he said was wholly inadequate, as they often have no accurate idea of the adequacy of their children’s swimming. Wellington County Grammar have taken a wide range of steps to reduce risk in the future. However the Headteacher said he was reluctant to introduce formal pre-trip assessment of swimming ability without central guidance. The expert gave specific recommendations of actions that should be taken to reduce deaths. ACTION SHOULD BE TAKEN I send this report to the Secretary of State for Education (whom the expert stressed was the appropriate body, rather than the Secretary of sate for Sport), to draw your attention to this reported risk, as I believe that the minister is in a position to take action. The expert recommends that the minister considers these actions which he believes will reduce deaths: 1. To review the curriculum and introduce appropriate swimming instruction, with an ambitious target of competence. 2. To include in DoE guidance to schools the risks of inexperienced ot weaker swimmers swimming in open and cold waters and the need for young people to know their swimming ability 3. To promote the adoption by schools as routine, prior to school trips and water events (including rowing), a proper test of swimming ability of each participant and using that in the risk assessments of the activity. E | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15" March 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. If you require any further information or assistance about the case, please contact the case officer, COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: [__‘ ay (uncle) for the family PEE The headmaster of Wallington County Grammar School Hesebererer HE he headmaster of Shawnigan Lake School Iam also sending this report to the following, who may have an interest: Ms Karen Bradley, The Secretary of State for Media Culture and Sport HE Principal Consultant, The Royal Society For The Prevention Of Accidents (ROSPA) Water Safety Consultant Iam 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 E [ ] lye 1-8 [SIGN ‘pp —
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.
SR D R34 $ Map, x MENT pon eve Rt Hon Damian Hinds MP Secretary of State Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT tel: 0370 000 2288 www.education.gov.uk/help/contactus Andrew Harris Senior Coroner London Inner South Southwark Coroners Court 1 Tennis Street London SE1 1YD Vi Me lees, Thank you for your report following the conclusion of the inquest into the tragic death of Abdul Jamal Ottun, in Canada, on 12 July 2015. This was received on 19 April 2018. | was saddened to hear about this tragic case. You highlight some extremely important issues in the report enclosed with your letter. | share the concerns you have identified, and it is important that we take steps to help prevent future tragedies of this kind occurring. | have noted your recommendations, and | can confirm that my department is making progress in the extremely important areas your report highlights. The new physical education curriculum, developed with a range of sector experts, was introduced in 2014. Swimming and water safety is compulsory in the national curriculum at primary levels - key stages 1 and 2. The curriculum sets out the expectation that all pupils should be taught to: « swim competently, confidently and proficiently over a distance of at least 25 metres *® use a range of strokes effectively; and e perform safe self-rescue in different water-based situations. i] 7 Whilst there are no specific statutory requirements on secondary schools to provide swimming lessons, the key stage 3 physical education curriculum sets out that pupils should build on and embed the physical development and skills learned in key stages 1 and 2, and become more competent, confident and expert in their technique. Swimming lessons are one way of doing this and swimming and platform diving are two of the permitted activities in the activity list for GCSE and A-Level PE. | can assure you that we are aware of the inherent risks of water-based activities and that my department is committed to reducing the number of. deaths by drowning. To this end, we tasked an independent group of experts from across the swimming sector to submit an independent report setting out recommendations for improving curriculum swimming as part of the Sporting Future strategy. The group published their report in July 2017 and we subsequently established an implementation group, and are currently reviewing the recommendations in the report. In response to the report, We have already provided schools with more flexibility to use their PE and School Sport Premium funding to support Top-up swimming lessons, as well as funding teacher training to support delivery of high quality swimming lessons. We also fully support the National Water Safety Forum’s National Drowning Prevention Strategy, which was launched in 2016. It aims to achieve a 50% reduction in drownings by 2026 by encouraging people to stay safe whilst enjoying themselves. The strategy includes a target for every child to have the opportunity to learn to swim and receive water safety education at primary schoo! and where required at Key Stage 3. The risks associated with water activities undertaken during outdoor education activities are a particular concern. Outdoor learning and educational visits do of course play an important part in the development of our young people. These activities often involve swimming and other water-based activities, and it is important that schools and colleges undertake a thorough risk assessment when planning such activities. E We are currently reviewing the guidance we provide to schools and colleges undertaking educational visits. Our intention is to remind schools and colleges " about the importance of careful planning when visits involve water based activities, especially where these are undertaken abroad. As part of our review, we have discussed with stakeholders how we can better signpost the advice and support that is available to schools and colleges on this important matter. We are due to publish revised guidance later in the year. | do hope that the steps we are taking that | have set out here reassure you that we are not complacent about the risks associated with swimming and other water-based activities. As you can see, we are working with sector professionals to ensure safety is improved, while children are still able to enjoy exciting educational experiences that broaden their horizons. Thank you for writing on this important matter. Noo | Cw Damian Hinds Secretary of State for Education Yours sincerely,
See every Prevention of Future Deaths report matching Andrew Harris, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.