Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0145, written 14 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 May 2018 |
|---|---|
| Reference | 2018-0145 |
| Deceased | Hans-Peter Schmidt |
| Coroner | Guy Davies |
| Coroner area | Cornwall& the Isles of Scilly |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Director, Heritage Attractions Ltd 1. 2. 3. 4. Kate Kennally, Chief Executive, Cornwall Council , Heritage Attractions Ltd , General Manager, Lands End Resort 1 CORONER My name is Guy Davies. I am Her Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly 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 7th July 2017 I commenced an investigation into the death of Hans-Peter SCHMIDT. The investigation concluded at the end of the inquest on 3rd May 2018. The four statutory questions - who, when, where and how – were answered as follows … ‘Hans-Peter SCHMIDT died on 17th June 2017 at Lands End, Cornwall from trauma consistent with an unwitnessed fall down a sheer cliff-face whilst cycling along the cliff edge in an area in which the footpaths are eroded and lead to the cliff edge.’ The legal conclusion of the inquest was that Hans-Peter Schmidt died an accidental death. The medical cause of death was (1a) multiple injuries, (1b) from a fall from a 1 cliff. 4 CIRCUMSTANCES OF THE DEATH . They were staying at Mousehole in West Cornwall. Herr 53 year old German national Herr Schmidt, was on holiday in Cornwall with his wife, Schmidt was a semi- professional cyclist, a member of the Frankfurt cycling club. On the afternoon of their arrival in Cornwall, 17th June 2017, Herr Schmidt set off on a cycle ride from which he never returned. Frau Schmidt raised the alarm later that same day. On the morning of Sunday 18th June 2017, search and rescue operations commenced which included a Coastguard helicopter. That morning Herr Schmidt’s body and bike was found at the foot of the cliffs at Lands End, south of the main Lands End holiday complex and near Greebs Farm. Police evidence ruled out any defects on the bicycle. Herr Schmidt was riding a high spec mountain bike, of several thousand pounds in value, which was well maintained. Police and RNLI evidence indicated that at the site of the accident the ground near cliff edge sloped at 45 degrees to sheer cliff face, made up of loose grit and dirt with areas of grass – it was a finding that this loose ground could have been a contributing factor. The footpaths appear eroded, unofficial pathways have formed, some slope towards and lead over the cliff edge. The finding of fact was that Herr Schmidt either rode straight off the cliff edge or that he had lost control of his cycle and then fell off the cliff. At the time of the accident there were no barriers at the edge of the cliff. The court heard evidence that on 30th April 2017 another fatality had occurred at almost exactly the same spot, involving a Mr Grzegorz Jachec. The conclusion of the inquest into the death of Mr Jachec found that he and his family had been walking the coastal path and that he had been ‘joking around’ at the fatal location and that he then disappeared. His body was found at the foot of the cliffs in almost the same spot that Herr Schmidt was later found. Slip marks were found on the sloped grass area on the cliff edge where Mr Jachec had been standing. 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. 2 The MATTERS OF CONCERN are as follows. – (1) The apparent lack of maintenance of the temporary rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017, namely those of Mr Jachec and Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property. (2) Regarding the lack of permanent barriers as recommended by the RNLI at the two hot spot sites discussed above. (3) The lack of internationally recognisable warning signs in accordance with British Signage Institute (BSI) guidelines to warn non-English speakers of the dangers presented by the cliffs as recommended by the RNLI. (4) The lack of uptake by the Lands End resort of the RNLI offer to provide training to staff. (5) The lack of warning signs and pictograms at discrete public locations within Lands End resort to promote awareness of the dangers presented by the cliffs. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [and/or your organisation] have the power to take such action, namely to… (1) Review the need for maintenance and inspection of the temporary and fragile nature of the rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017 including that of Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property. (2) Consider installing permanent barriers such as a wooden fence as recommended by the RNLI at the two hot spot sites discussed above. (3) Consider appropriate placement of internationally recognisable warning signs in accordance with British Signage Institute (BSI) guidelines to warn non-English speakers of the dangers presented by the cliffs as recommended by the RNLI. (4) Consideration to be given by the Lands End resort to accepting the RNLI offer to provide training to staff. (5) Consider appropriate placement of warning signs and pictograms at 3 discrete public locations within Lands End resort to promote awareness of the dangers presented by the cliffs. (6) Cornwall Council to consider exercising its statutory powers to ensure the necessary safety measures are implemented at the Lands End resort and in the coastline and cliffs below Greeb Farm. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 9th July 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 Chief Coroner and to the following Interested Persons, and to the family of Mr Jachec. I have also sent it to the investigating police officers, who may find it useful or of interest. , RNLI Community safety partner, and to 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 14th May 2018 Guy Davies 4
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