Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0055, written 15 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2019 |
|---|---|
| Reference | 2019-0055 |
| Deceased | Dwayne Thompson |
| Coroner | Alison Mutch |
| 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: Health and Safety Executive (HSE) and
Royal Society of Prevention of Accidents
CORONER
tam Alison Mutch ,Senior Coroner, for the coroner area of South Manchester
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
| INVESTIGATION and INQUEST
|
On 29th June 2078, | commenced an investigation into the death of Dwayne
Daniel Ryan Thompson. The investigation concluded on the 17" January 2019
and the conclusion was one of accidental death.
The medical cause of death was 1a hypoxic brain injury;1b freshwater drowning
4 | On 28th June 2018 Dwayne Daniel Ryan Thompson went with friends to the
Reservoir at Audenshaw. Whilst swimming he got into difficulties and went
underwater. Emergency services recovered him from the water and transferred
him to Tameside General Hospital. Resuscitation continued. He had suffered a
catastrophic brain injury as a result of being underwater. He died at Tameside
General Hospital on 28th June 2018.
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 inquest heard that Dwayne Thompson had significant learning disabilities.
This reservoir had a fence to prevent access but this was regularly damaged
and access was gained with relative ease by locals who used the reservoir to
|e in/cool down in during the heat of the summer. It was unusual in having a
fence and the majority of reservoirs were easily accessible by the public.
There was signage to warn of the risks of swimming in reservoirs. This signage
was used across all reservoirs including those with open access to them. It was
the main way in which the utility company made the public aware of the risks of
the reservoirs. The signage complied with the HSE guidance but the inquest
heard that the signs had been in existence for many years and there was no
evidence that the needs and understanding of those with learning disabilities
had been considered when they were devised.
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 12" April 2019. |, 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 to the following
Interested Persons namely Mother of the deceased and
United Utilities who may find it useful or of interest.
lam 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.
Alison Mutch OBE
HM Senior Coroner
15" February 2019
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.
RoSPA 28 Calthorpe Road Birmingham, B15 1RP United Kingdom T: +44 (0)121 248 2000 help@respa.com accidents don’t have to happen weww.rospa.com Patron: Her Majesty The Queen 0121 248 2020 Alison Mutch OBE HM Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG coroners.office@stockport.gov.uk By Post & Email 12th April 2019 Dear HM Senior Coroner, RE Death of Mr Thompson on 28th June 2018, and report to prevent future deaths Thank you for the letter of 15th February 2019. This letter sets out the steps we have taken to date and our further action. Background The Royal Society for the Prevention of Accidents (RoSPA) is a charity in existence for over a century, we are concermed with the prevention of accidents across the full range of life, both in the UK and abroad. RoSPA has no regulatory role, or enforcement powers. In considering our response we held discussions with: The Health and Safety Executive; United Utilities as the duty holder at Audenshaw Reservoir; the Inland Waters Group, a national group of companies with duties for inland waters within the National Water Safety Forum; the National Fire Chiefs Council drowning prevention lead. The following responses are that of ROSPA. We have not visited the location in question and offer no commentary with respect to measures in place. Our key actions are numbered to the structure of your letter. A future without drowning: the UK drowning prevention strategy RoSPA host and provide the secretariat to the National Water Safety Forum (NWSF), a collective network that includes landowners, rescue organisations and sporting bodies. In 2016 it published the UK’s first national drowning prevention strategy: A future without drowning (1). Our drowning prevention activity, and those of the NWSF network, is aligned to towards this strategy. Of particular note to this response are the targets for Community risk plans, Awareness of risk, Swimming and water safety education. The Royal Society for the Prevention of Accidents en A company limited by guarantee registered in England with No. 231435, a INVESTORS. \ Registered office: RaSPA House. 28 Calthorpe Road, Edgbaston, Birmingham, 815 IR IN PEOPLE | °°" Registered Charity No. 207823 RoSPA 28 Calthorpe Road | Birmingham, B15 1RP | Untted Kingdom T: 044 (0)121 248 2000 help@rospa.com accidents don’t have to happen fear resps’cora Patron: Her Majesty The Queen Risk management and warning signage for the public Under UK health and safety law, it is incumbent upon the duty holder to maintain a system which identifies and manages risks to those affected by the workplace. RoSPA would expect the drowning of a member of the public at a reservoir to be a foreseeable risk. The question of how this is subsequently managed, by law, rests with the duty holder. We publish specialist, collectively agreed guidance to assist with these decisions. Further, we have previously assisted Water UK in the production of their guidance for reservoir safety. There is a range of opinions on the role and effectiveness of ‘safety signage’ in public settings as a strategy to reduce drowning. Signage at inland water settings has developed through risk assessment or custom and practice, rather than a specific duty in law to place them in these settings. RoSPA’s view is that signage can be effective if applied as part of an overall set of measures, but is very much secondary to interventions such as clear level footpaths or limited use of barriers at key points to deflect falls. Our preferred approach is to offer an integrated set of messages i.e. on website/media, targeted awareness campaigns and if needed specific advice on site. Action 1. We have recently updated our national guidance: Managing Safety at Inland Waters (2). This is our principal advice for duty holders, and it includes examples and approaches such as risk communication and identification of hazards. The latest edition was published December 2018, and it is our intention to contact all Local Authorities and known key duty holders including reservoir companies to inform them of the updated advice before the end of 2019. Cold Water Shock: awareness of this principal risk factor RoSPA and other specialists in the drowning prevention community are strongly of the opinion that Cold Water Shock (CWS) is the principal danger to life for those that enter water quickly in the UK. The extent of the danger is not understood well by the majority of the UK population. CWS is an involuntary physiological response that overwhelms a person’s ability to control breathing and affects swimming performance. This creates a sense of panic and rapid breathing, which can lead to aspiration of water and ultimately start the drowning process, resulting in death or life-changing injury. The critical window is the first few minutes of entry, after which the person's body acclimatises to the temperature. We have previously funded research to better understand this event (3). q The Royal Society for the Prevention of Accidents a 4 company limited by guarantee registered in England with No, 231435 ¢ } INVESTORS | , aad j Registered office: RoSPA House, 28 Calthorpe Road, Edgbaston, Birmingham, B15 1RP Gold Registered Charity No 207823 IN PEOPLE RoSPA 28 Calthorpe Road Birmingham, B15 1RP United Kingdom T. +44 (0)121 248 2000 accidents don’t have to happen ae Patron: Her Majesty The Queen. CWS can be stopped before it escalates into a drowning. In addition to warnings, education on practical steps such as Float First, Float To Live, and Swim Safe campaigns could save a life. Action 2. Steps that raise awareness of this principal risk, and importantly why it is a risk at a given location, will have a positive impact. It is our aim to include members of Water UK as a key group before the end of 2019 to this end. Autism as a risk factor There is published evidence that highlights an increased risk of drowning among younger children. We have searched our fatal drowning databases for incidents between 2007- 2018 and found: eight drowning incidents involved persons with autism reported as a pre-existing condition; of these, two were children under 10-years-old, the remainder between 20-30 years-old; all were male. In the same period over 8000 people died due to drowning. Action 3. The impact of autism on non-fatal drownings is not known in the UK. We have commissioned an analysis of trauma data to better evidence a collective understanding of autism as a risk factor. This is expected to be ready for publication before the end of 2019. Action 4. We will support the fire services’ and partners’ efforts to develop and formalise a national education pack to help the water safety or general safety practitioner to understand autism better. At the time of drafting this response | am not in receipt of an agreed publication date, but will confirm in writing by the end of July 2019. Community feve! plans Drowning is a complex event; its causes can be found in the wider community as much as the immediate location, for example swimming ability or infrastructure that requires improvement. In order to prevent the next drowning event, consideration of the community as a whole is needed. During 2018 we worked with The Manchester Water Safety Partnership to review drowning incidents within Manchester City Centre, and to develop a plan for the City Centre as a whole to stop the next drowning. This was presented to the Greater Manchester Mayor in November and launched in December (3). The review considered waterways within the city, and included land within Manchester and Salford Local Authorities. Over the study period we found 28 drownings within the City Centre. We identified a further 111 drownings across other Greater Manchester authorities, to the best of our knowledge, there are no equivalent plans in place. Action 5. It is our intention to invite all Greater Manchester Local Authorities to a workshopto consider the findings from the City Centre review and the above points. The Royal Society for the Prevention of Accidents ~. A company limited by guatantee registered in England with No, 231425 INVESTORS | . Registered office: ReSPA House, 28 Calthorpe Road, Edgbaston, Birmingham. B15 1RP* IN PEOPLE ld Registered Charity No. 207823 q RoSPA 28 Calthorpe Road Birmingham, B15 1RP } United Kingdom T. +44 (0)121 248 2000 accidents don’t Hose sompoail Patron: Her Majesty The Queen. We were deeply saddened to hear of Mr Thompson's death. If it is considered helpful we would be willing to meet with Ms Thompson. Thank you for the opportunity to respond. Yours sincerely, Head of Leisure Safety co. Errol Taylor, Chief Executive, ROSPA NFCC Drowning Prevention Group Manchester Water Safety Partnership The Health and Safety Executive United Utilities Water UK NWSF Inland Waters Group The Royal Society for the Prevention of Accidents es, @ i sid ae renee ey ae BIS IRP q } INVESTORS | J I. a iT, \ } Registered Charity No. 207821 " _<” IN PEOPLE
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