Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0094, written 3 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Apr 2018 |
|---|---|
| Reference | 2018-0094 |
| Deceased | Casper Blackburn |
| Coroner | 2018-0094 |
| Coroner area | Manchester 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Peel Holdings; 2. Trafford County Council; 3. Canals and Waterways Agency; 1 | CORONER | am Rachel Galloway, assistant coroner, for the coroner area of South Manchester 2 | CORONER'S LEGAL POWERS | 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 the12th October 2017 an inquest was opened into the death of Casper Blackburn. The evidence was heard at inquest o the 237 March 2018 and my conclusions were given on the 29" October 2018. The conclusion left was a narrative conclusion: “Casper died from the recognised complications of accidentally entering the canal contributed to by very poor lighting”. The medical cause of death was: 1a drowning. 4 | CIRCUMSTANCES OF THE DEATH Casper Blackburn died in the early hours of the morning on the 1 October 2017 after he entered the Bridgewater canal in the vicinity of St Pau!'s Church on Springfield lane, Sale in unclear circumstances. Itis likely that very poor lighting in the area and a degree of intoxication on Casper’'s part contributed to his death. 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. — The lighting in the area where Casper likely accidentally entered the canal was extremely poor. There is no CCTV in the area and therefore what precisely happened on the morning of Casper's death is unclear. Evidence was heard that police attended the scene at night on a date following Casper’s death. The area was so dark that it was very difficult to discern the canal from the grass verge or the path. | am concerned that “future deaths might occur if action is not taken to address this. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2g" May 2018. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and the family of Casper Blackburn, who may find it useful or of interest. (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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Rachel Galloway HM Assistant Coroner 03/04/2018 Gan nN
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.
Trafford Council
2™ Floor, Trafford Town Hall Talbot Road
Stretford, Manchester, M32 OTH
TRAFFORD oral
ee
COUNCIL Telephone 0161 912 4879
Fax 0161 912 4294
Our Ref: TR/007348
5 Your Ref:
HM Coroner's Office Date: 9 May, 2018
The Coroner’s Court
1 Mount Tabor
Stockport RECEIVED
SK1 3AG
14 MAY 2013
rn ee CY.
Dear Sirs
RE: Regulation 28: Report to prevent future deaths
Casper Blackburn.
| refer to your report on this matter dated 3 April 2018
Trafford Council takes this matter very seriously and since the unfortunate and tragic
death of Casper has set up a multi-agency Trafford Water Safety Group to consider
matters of water safety across the Borough.
Therefore, in response to your report the Council has contacted both the Trafford Water
Safety Group and the Bridgewater Canal Company Limited and has brought these
matters to their attention. The Council understands that the Chair of the Trafford Water
Safety Group and a representative of Pee! will be meeting in May to discuss an action
plan for alleviating any future danger.
Unfortunately, the Council has a very limited ability to take direct action as it is not the
relevant landowner in respect of the path which runs alongside the canal, nor is it
responsible for the public right of way which runs over that path. In both instances the
responsible party is the Bridgewater Canal Company Limited. However, the Council has
approached the Bridgewater Canal Company to seek to find a resolution to improve the
safety of the users of the path and to improve safety measures
Yours faithfully
Tim Rhodes, Principal Solicitor EGEI
Legal & Democratic Services
Trafford Borough Council
Director of Legal and Democratic Services: Jane Le Fevre
TR/ 007348 / 530923
/ Version : Authorised and regulated by the Solicitors Regulation Authority SRA No.65042
The Bridgewater Canal Company Limited
Peet Dome, intu TRAFFORD CENTRE, TRAFFORDCITY, Manchester, M17 8PL
TEL: 0161 629 8432 www. bridgewatercanal.co.uk www.peel.co.uk
7
is
Win wit
T—
24 May 2018
HM Coroner Manchester South
Coroner's Court
1 Mount Tabor Street
Stock
Scenes RECEIVED
25 MAY 2018
Dear Madam C
Caspar Blackburn (deceased)
Thank you for your letter addressed to Peel Holdings which has been passed to The
Bridgewater Canal Company Limited (“BCC”), the statutory navigation authority for and the
company that owns and manages the Bridgewater Canal ("the canal"). BCC is a wholly
owned subsidiary of Peel Holdings Land and Property (UK) Limited.
We acknowledge receipt of your letter and Regulation 28 report dated 3 April 2018 and note
in particular the observations in section 5 of your report, which have been considered very
carefully.
Before responding to your observations, we would like to express our sincere sympathy to
the family of Mr Blackburn and our sadness at his death.
Background information
The canal is a 39 mile canal between Runcorn and Leigh and the towing path which runs
alongside the canal provides a multi-user route.
There are approximately 4,000 miles of inland waterways in the UK managed by around 50
Navigation Authorities and other organisations. The Canal and River Trust is the largest of
these managing over 2,000 miles of canals and rivers, most of which are accessible by the
public. By comparison the canal is 39 miles long and is one of the few canals not to be
nationalised in the 20" Century. The public have had access to the Bridgewater Canal since
it was completed over 250 years ago.
BCC is a member of a number of water safety groups and federations of canal users and the
prevention of incidents, including drowning, is always a priority for BCC and these groups.
Decisions in relation to safety are always taken very seriously and are made by BCC with as
much input from the groups as possible, as well as consultation with canal users wherever
possible.
The canal is of great historical importance locally and, indeed, globally and it brings
extensive environmental and heritage benefits to the areas it passes through. In recognition
of this a project to regenerate the canal, promoted and funded in part by the Bridgewater
A member of the Peel Land and Property Group
Registered Office: Peel Dome, intu TRAFFORD CENTRE, TRAFFORDCITY, Manchester, M17 8PL.
Registered Number 6805592 England and Wales
Canal Trust, commenced in 2003. Just over 26 miles of the canal towpath has been
improved as a result of this project to date, with further work planned for the future.
The aim of the regeneration is to provide a better surface for the towpath, increased seating
and public information for the canal, and provide improved access to encourage new users
of the canal. The regenerated sections of the canal form the Bridgewater Way. The area in
which this sad incident occurred was in an area that had been regenerated.
Information relating to the canal is available on the Bridgewater Canal website which can be
found at www.bridqewatercanal.co.uk.
The website includes a code of use for all users of the canal, including pedestrians. The
code of use contains a number of warnings regarding using the canal, including highlighting
the fact that towing paths are unlit. There are also a number of natural and historical features
along the canal which may present a hazard for pedestrians and due to the close proximity
of deep water, it is therefore not recommended to use the path in the hours of darkness and
in poor light conditions.
Response to concerns
The towing path in the regenerated areas consists of a light golden colour stone and is
approximately 1.8 metres wide in the area in question. There is then a grass verge
approximately 0.5 metres wide before the coping stones bordering the canal itself.
It is not intended that lighting will be introduced to the canal by BCC. To introduce lighting in
the urban and rural areas would have a significant adverse impact on the heritage and
natural environment of the canal which would be entirely detrimental to local areas for users.
of the canal, residents and the ecology and wildlife which thrives along the canal. It may also
present other safety issues and encourage night time use which is not advisable. We
understand that this is also the policy of the Canal and River Trust.
Thank you for your report dated 3 April 2018 and for the opportunity to respond to your
observations.
For and on behalf of The Bridgewater Canal Company Limited
Position... eee cae
Dated........24. 0A OMT
CH.
Canal &
m= <a River Trust
Coroner's Office
1 Mount Tabor Street
Stockport
SK1 3AG
FAO Ms Rachel! Galloway
Your Ref: 8398/CH
20" April 2018
Dear Ms Galloway,
RE: Casper Harvey Blackburn
Thank you for your letter dated 3% Apri! 2018, addressed to the Trust's Chairman, Allan Leighton.
As the local safety advisor for the area in which Casper sadly died, your Jetter has been passed to
me to reply on behalf of the Canal & River Trust (‘the Trust’) on this occasion, however, please can |
ask you to address all such correspondence in the first instance to:
Head of Legal and Governance Services
Canal & River Trust
First Floor North, Station House
500 Elder Gate
Milton Keynes
MkK9 1BB
May | take this opportunity to extend the Trust’s sincerest condolences to Casper's family for their
loss; our thoughts and sympathies are with them at this extremely difficult time.
Turning to the Regulation 28 report enclosed with your letter, | can see that it recommends action
should be taken regarding lighting on the towpath of the Bridgewater Canal where it is believed
likely that Casper entered the water.
However, the Canal & River Trust has no jurisdiction or responsibilities regarding the Bridgewater
Canal or the land at this location. | believe is in fact the responsibility of Peel Holdings and because
| can see that the Regulation 28 report is being sent to Peel Holdings, in the circumstances | do not
believe the Trust is required to take any further action
Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB
T 0303 040 4040 E customer.services@canalrivertrust.org.uk www.canalrivertrust.org.uk
Patron: H.R.H. The Prince of Wales. Cana! & River Trust, a charitable company limited by guarantee registered in England and Wales
with company number 7807276 and registered charity number 1146792, registered office address First Floor North, Station House, 500
Elder Gate, Mitton Keynes MK9 1BB
Canal &
m <a8 River Trust
Please do not hesitate to contact me if the Trust can be of any further assistance in this matter.
Yours sincerely,
ee f-———
Safety Adviso
Tel 01606 723801
Mob __07702 847012
Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB
T 0303 040 4040 E customer.services@canalrivertrust.org.uk www.canalrivertrust.org.uk
Patron: H RH. The Prince of Wales. Canal & River Trust, a charitable company limited by guarantee registered in England and Wales
with company number 7807276 and registered charity number 1146792. registered office address First Floor North, Station House, 500-
Elder Gate, Milton Keynes MK9 1BB
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