Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0075, written 27 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 | 27 Feb 2019 |
|---|---|
| Reference | 2019-0075 |
| Deceased | Shane Gray |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Jeffrey Sills Chief Executive Park Holiday UK Limited Glovers House Glovers End Bexhill-on-Sea East Sussex TN39 5ES 1 CORONER I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 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 26th July 2018 I commenced an investigation into the death of SHANE GRAY, aged 27 years. The investigation concluded at the end of the inquest on 27th February 2019. The conclusion of the inquest was that Shane died an accidental death. 4 CIRCUMSTANCES OF THE DEATH On 25th July 2018 Shane Gray was working for Doe Caravan Transport Ltd erecting and dismantling Caravans on the Lakeside Caravan Park. It was a hot day. When the work for the day was complete Mr Gray decided to go for a swim in Leythorne Lake close to where he was working and which was part of the Lakeside Caravan Park. There were no signs at this part of the site showing that swimming was prohibited. He entered the water but after a short period he got into difficulties, being unable to breathe, and despite calling out to his friends, he went under the water and subsequently drowned. 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. – (1) That there was inadequate signage in this particular area of the Site where Shane entered the Lake warning him that Swimming was not permitted. (2) The area close to the Lake (where the accident occurred) is to be occupied by families with young children and there is no physical barrier to prevent young children entering the Lake.. (3) The signage that is in place in other parts of the sites in a text format (with no 1 pictorial form) and therefore this signage does not provide for those individuals who cannot read or for children who are not of a reading age. (4) Contractors who are working on the site are not directly made aware of the rules relating to the Lakes. Reliance is placed solely on these Contractors having seen the signs upon entering the Site. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 24th April 2019. 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:- , partner of the deceased, , mother of the deceased. Doe Caravan and Transport Ltd 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 27th February 2019 Penelope Schofield, Senior Coroner 2
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.
PARK HOLIDAYS
Glovers House, Glovers End
Bexhill-on-Sea
East Sussex, TN39 5ES
T: 01424 234 234
1 8 APR 2019 E: info@parkholidays.com
VW: www.ParkHolidays.com
FAO: Ms Penelope Schofield
Senior Coroner
Coroner's Service
West Sussex County Council
County Record Office
Orchard Street
Chichester
PO19 1DD
Dear Ms Schofield,
| write to respond on behalf of Park Holidays UK Limited ("the Company") to the Regulation 28
Report issued on 27 February 2019 following the inquest into the death of Mr Shane Henry Steven
James Gray ("Mr Gray"). The Company has carefully considered the report and the concerns
contained therein.
The Company takes its responsibility regarding the Health and Safety of their employees and
visitors very seriously and were shocked to hear of the tragic death of Mr Gray. We wish to offer our
sincere condolences, through your office, to the family and friends of Mr Gray.
We address each matter of concern in order:
(1) There was inadequate signage in the particular area of the Site where Shane entered the
Lake warning him that Swimming was not permitted.
Chichester Lakeside Holiday Park (‘the Park") contains 12 fishing lakes and is set over 150 acres.
The Lake Mr Gray entered is known as "Leythorne Lake" ("the Lake"). The Lake is located at the
right-hand side of the entrance to the Park and borders the A27. At the time of Mr Gray's death
there were eight warning signs around the Park including one at the entrance to the Park which
would be passed by all vehicular traffic. For pedestrians there was signage on all designated paths
on the approach to the Lake.
The Company cannot be specific about where Mr Gray entered the water as no one from the
Company witnessed the incident.
An Open Water Risk Assessment was carried out on 10 July 2018, before the incident. At that time,
although extensive signage was in place at the Park, an action point was noted that the quantity of
life rings and signage be reviewed. The new signage was ordered and delivered in August 2018 and
was installed during August / early September. There are now 24 signs around the Park with two
“e
silver Registered office: Glovers House, Glovers End, Bexhill-on-Sea, East Sussex, TN39 5ES.
The place of registration is England and Wales, Registration Number 02434151.
xy INVESTORS | .
” IN PEOPLE
signs on the Lake's edges, one on the "camp site side" and one on the opposing side along a
designated pedestrian path There are no signs along the edges that border the A27 due to the thick
trees that border the lake/road
The Company considers the number of signs around the Park as adequate to highlight the potential
dangers of deep water and prohibit swimming.
(2) The area close to the Lake is to be occupied by families with young children and there is no
physical barrier to prevent young children entering the Lake
The Company does not consider It to be practical to erect physical barriers around the Lake Some
of the lakes at the Park, including the Lake, are leased as syndicate lakes to nearby fisheries which
means that the fisheries have a concession and are allowed to fish on the lakes One of the lakes at
the Park 1s also used for water skiing
The Company does not agree a physical barrier is necessary in any event The lakes are viewed as
having "natural barriers" where they are surrounded by hedges, brambles or vegetation. Cleared
areas around the lakes are manmade in order to allow the fishermen and water skiers access to the
lakes We would also note that tt is not a legal requirement for bodies of water to be fenced off
The Company ts of the view that the risk of young children entering the lake ts controlled by advice
to parents contained in the holiday caravan rental safety information pack which states
"Your safety is paramount on the park and we strongly advise all those with children to be
extra vigilant when they are walking or playing on the park unsupervised Most of our lakes
are fishing lakes and as such are not fenced off — please ensure you do not allow anyone to
enter the lake to swim or paddle — these lakes can be very deep and are full of weeds and
obstructions you cannot see.
In the event of an emergency signs and life buoys are located around each lake with
emphasis on the approach routes Raise the alarm immediately calling the emergency
services stating the lake at which the emergency Is at Please also notify the Park Warden
number which is again listed on the signs
Dogs should not be allowed to access the water — it is not hygienic water ”
(3
S
The signage that is in place in other parts of the sites in a text format (with no pictorial form)
and therefore this signage does not provide for those individuals who cannot read or for
children who are not of reading age
The Company would reiterate that children who are not of reading age are required to be supervised
at all times whilst at the Park and parents are advised accordingly in the holiday caravan rental
safety information pack
The Company takes its responsibility for health and safety very seriously and will be, for the
avoidance of any doubt, erecting pictorial signage alongside the existing signs to identify "no
swimming" as a visual sign as well as the written word The Company has ordered pictorial signage
and envisages that this will be in place by June 2019
(4) Contractors who are working on the site are not directly made aware of the rules relating to
the Lakes Reliance ts placed solely on these Contractors having seen the signs upon
entering the site
The Company carries out open water risk assessments for staff safety These primarily relate to the
Fisheries Wardens who do, on occasion, have need to access the water and/or lake edges In this
regard, the Company provides these wardens with life jackets to be used when undertaking such
tasks The Company does not agree that it would be practical to warn every contractor on site as to
the dangers of the lakes, as a rule. The Company retains the services of contractors to carry out a
number of different tasks, such as refuse collection and cleaning for example It would be
inappropriate to alert all contractors to all risks at the Park Risk assessments are specific to the
expected tasks and are only provided to staff who are to work directly on the lakes.
The Company also has a pre-qualifying questionnaire scheme, entitled the Contractor Competence
Assessment Scheme ("CCAS") whereby all contractors are required to provide their risk
assessments, method statements and proof of insurance to demonstrate that they are responsible
contractors The Company now retains a third party to manage the scheme and contractors are
required to be part of the CCAS
Although some reliance is, reasonably, placed on the contractors ensuring the health and safety of
their own staff, the Company ts prepared to provide for those contractors engaged by the Company
to be given a leaflet about the lakes when they sign in at reception
The Company is aware of its statutory and common law duties towards visitors at the Park and
considers that the signage in place satisfies the Company's duty of care to ensure visitors’
reasonable safety. Signage !s situated on the entrance to the Park itself and also on the approach to
each lake
We have been advised that the House of Lords directed in Tomlinson v Congleton BC [2003] UKHL
47 that
"any premise can be said to be dangerous to someone who chooses to use them for
some dangerous activity The fact that such people take no notice of warnings cannot
create a duty to take other steps to protect them _ it will be extremely rare for an occupier of
land to be under a duty to prevent people from taking risks which are inherent in the
activities they freely choose to undertake upon the land If people want to climb mountains,
go hang-gliding or swim or dive in ponds or lakes, that is their affair Of course, the
landowner may for his own reasons wish to prohibit such activities He may think that they
are a danger or inconvenience to himself or others Or he may take a paternalist view and
prefer people not to undertake risky activities on his land. He is entitled to impose such
conditions, as the Council did by prohibiting swimming But the law does not require him to
do so"
The Company also submits that any contractors working on site are aware that swimming is
prohibited in the lakes due to the signage around the Park
Moreover, we have also been advised that the Court of Appeal held in English Heritage v Taylor
[2016] EWCA Civ 448 that, in order to comply with their statutory duties, where it is not clear
whether a risk is self-evident or not, an occupier may take reasonable measures to warn against
dangers but the steps need be no more than reasonable steps It ts the Company's view that the
steps taken to date to prevent reoccurrence of this incident are reasonable
The Company therefore does not agree that anything more ought to, or can practically, be done to
alert contractors to the rules relating to the lakes
Following the inquest into the death of Mr Gray, the Company consulted the counsel of the Senior
Environmental Health Officer from Chichester District Council ("the EHO") who visited the Park to
review their safety management The EHO was pleased with the Company's systems and their
review of the Open Water Risk Assessment following the incident He also agreed that the steps
taken by the Company to date are practicable and appropriate in terms of seeking to prevent
reoccurrence of this tragedy
The Company does not take the incident lightly and is eager to ensure that this does not happen
again and that the Park is a safe family holiday environment for all visitors
We hope the above ts of assistance and that it addresses all of the issues raised in the Coroner's
report
Yours sincerely,
Jeff Sills
Chief Executive Officer
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