Prevention of Future Deaths reports · 2019

David Dooley

Regulation 28 report to prevent future deaths, reference 2019-0127A, written 10 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Apr 2019
Reference2019-0127A
DeceasedDavid Dooley
CoronerGilva Tisshaw
Coroner areaBrighton and Hove
CategoryPolice related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

CORONERS SOCIETY OF ENGLAND AND WALES
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

THIS REPORT IS BEING SENT TO:

1. Chief Inspector Andrew Bennett, Sussex Police

CORONER

Lam Gilva Dagmar Jane Tisshaw, Assistant Coroner, for the City of Brighton and
Hove

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 23" October 2018 an investigation into the death of David DOOLEY was
commenced. The investigation concluded at the end of the inquest on 19 March
2019.The conclusion of the inquest was ACCIDENTAL DEATH as set out on the
attached document.

CIRCUMSTANCES OF THE DEATH
See Record of Inquest

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) The exact location of the life lines on Brighton seafront were not known to the
Police officers who attended the scene of the incident. Mr Dooley’s friend
informed security at the local night club that he believed that Mr Dooley was in
the sea and the police officers attended very quickly. The location of the life

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

lines were not known to the police officers who attended the beach. A life line

had to be brought from the Police Station. As a consequence, there was a

delay in a life line being thrown to Mr Dooley. There was in fact a life line 30
metres from where Mr Dooley’s friend had first alerted the night club security
that Mr Dooley was in the sea. Although there was a delay in attempts being
made to throw Mr Dooley a life line, taking into consideration the adverse
weather conditions (Storm Callum) and sea conditions, even if a line had been
thrown earlier, | consider it would not have been able to be thrown to Mr Dooley
successfully.

(2) Steps should be taken to increase the police awareness of the location of life
lines and their use, so that they can be used more expeditiously.

(3) Steps should be taken to increase the public awareness of the dangers of the
sea and the risks of entering the sea when having consumed alcohol and/or
having taken drugs.

(4)_It should be noted that I have spoken with a representative of Sussex Police

and they have looked closely at this incident on the 13%
ctober and have made significant changes in their water safety training.
In addition, they are considering this information being included on the AX
Mapping System.

(5) As regards increasing public awareness as to the dangers of swimming whilst
under the influence of alcohol or drugs and in adverse weather conditions,
liaison should be undertaken with representatives of night club security and
representatives of the Seafront Operations Manager's Office and the Local Sea
Safety Forum who have high levels of experience in this area.

6 ACTION SHOULD BE TAKEN —

In my opinion action should be taken to prevent future deaths and | believe you
AND 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 15* June 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 ;

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.].TISSHAW, BA(LAW)HONS

| have also sent it to:-

1. | Seafront Office Manager, Brighton

Who may find it useful or of interest.
1am 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: 10° April 2019 SIGNED BY: ~”

|
H

ton and Hove

Responses

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.

Response from Sussex Police (PDF)
HM Assistant Coroner Gilva D.J Tisshaw BA (LAW) HONS
The Coroner’s Office

Woodvale, Lewes Road

Brighton

BN2 308

30" May 2019

Private and Confidential

Dear HM Assistant Coroner Gilva D.J Tisshaw,

RE: Sussex Police response to the Regulation 28 notice issued by HM Assistant Coroner Gilva D J Tisshaw
BA (LAW) HONS following the inquest into the death of Mr David Dooley.

Thank you for including Sussex Police within the scope of this notice. | welcome the notice as it is vital that all
public authorities learn from previous incidents and strive to make improvements. Whilst it was recognised at
the inquest that the tragic circumstances of Mr Dooley’s death could not have been prevented, it is clear there is
some learning for Sussex Police.

' shall deal sequentially with the 5 points you raise:

1. The exact location of the life lines on Brighton seafront were not known to the police officers who
attended the scene of the incident. Mr Dooley’s friend informed security at the local night club that he
believed that Mr Dooley was in the sea and the police officers attended very quickly. The location of the
life lines were not known to the police officers who attended the beach. As a consequence there was a
delay in a life line being thrown to Mr Dooley. There was in fact a life line 30 metres from where Mr
Dooley’s friend had first alerted the night club security that Mr Dooley was in the sea. Although there
was a delay in attempts being made to throw Mr Dooley a life line, taking into consideration the adverse
weather conditions (storm Callum) and sea conditions, even if a line had been thrown earlier, | consider
it would not have been able to be thrown to Mr Dooley successfully.

2. Steps should be taken to increase the police awareness of the location of life lines and their use, so that
they can be used more expeditiously.

3. Steps should be taken to increase the public awareness of the dangers of the sea and the risks of
entering the sea when having consumed alcohol or having taken drugs.

4. It should be noted that | have spoken with a representative of Sussex Police EE and they
have looked closely at this incident on the 13" October 2018 and have made significant changes in their
water safety training. In addition, they are considering this information being included on the AX
mapping system.

5. As regards to increasing public awareness as to the dangers of swimming whilst under the influence of
alcohol or drugs and in adverse weather conditions, liaison should be undertaken with representatives
of night club security and representatives of the seafront operations managers’ office and the local sea
safety forum who have high levels of experience in this area.

Sussex Police Response:

HM’s Assistant Coroner’s comments in relation to the circumstances of Mr Dooley’s tragic death have been fully
examined and noted by senior officers within Sussex Police. We are grateful for those comments and can assure
HM Assistant Coroner that we take matters of water safety extremely seriously.

1. The officers and staff that attended the tragic incident in which Mr Dooley lost his life did know of the
existence of publicly available throw lines/rings, but did not know their exact location. There will be
more consistency of awareness in the future, as all staff will receive recently developed prompt cards
showing the location of all coastal throw rings in Brighton & Hove.

Throw lines in police Response vehicles had been introduced two months earlier (August 2018}, but
those first on scene were part of a night time economy patrol and did not have immediate access to a
response vehicle. A throw line was requested and taken to the scene, arriving 10 minutes after the
request was received from officers at the scene, and within 15 mins of the first police sighting of Mr
Dooley in the sea. The Assistant Coroner has made it clear that even if a line had been thrown earlier,
they consider that it would not have been able to be thrown to Mr Dooley successfully.

2. Following this tragic incident the location of publically available throw lines and rings is more widely
known among officers and staff. Acting on the recommendations of the Coroner's report, prompt cards
showing the location of the 25 throw rings currently provided by Brighton & Hove City Council have
been obtained and have been sent to all Police officers and staff on Brighton & Hove Division.

It is the intention to replicate this process across all divisions within the Sussex Police area that have
coastal areas or large expanses of water. Chief Inspector Bennett will ensure this is completed by 1% July
2019.

3. In seeking to address recommendation 3 in the regulation 28 notice, a Brighton & Hove Division senior
manager has met with the Royal Life Saving Society UK (RLSSUK) and now sits as a Sussex Police
representative on the Brighton & Hove Coastal Water Safety Forum (BHCWSF). Attendees at the forum
come from various agencies including local council, seafront office, local policing and local business
representatives.

In relation to raising awareness of the dangers of the sea and the risks of entering the sea when having
consumed alcohol or having taken drugs, at their meeting on the 2" May 2019, the BHCWSF discussed a
wide range of ideas to spread greater awareness of water safety.

Although not taking the lead in this, Sussex Police are fully engaged with and support this activity. It will also
feature in the ‘Keeping safe in the summer campaign ‘a partnership led initiative in the city.

4,

Following on from previous action taken by Sussex Police in relation to water safety awareness and
additional training for police officers and staff, ‘throw lines’ were purchased and made part of the
standard equipment for all Sussex Police marked Response vehicles in August 2018. In November 2018
throw lines were also introduced as standard equipment on all marked police vehicles in Sussex. In early
2019 this was further enhanced with the introduction of the joint Surrey and Sussex force policy on
‘Water Safety for first responders’ (1184/2019). This policy document also includes a comprehensive
toolkit for officers and staff, and also a guidance sheet on the effective use of the throw lines now
available in all marked police vehicles.

As previously explained, there are 25 throw rings situated along the seafront of Brighton & Hove, the
location of which have been mapped and recorded on prompt cards for Police officers and staff. The
intention is to share this with the Brighton & Hove Crime Reduction Partnership which will include night
time economy workers such as door staff. Although prompt cards have been provided to officers and
staff showing the location of coastal throw rings, the longer term aim is to have these locations also
available on our Sussex Police digital mapping system. There are some technical challenges but Ci
Bennett is engaged at the appropriate level and aims to finalise this by 1°* September 2019.

Changes to our standard operating procedures within the Sussex Police Contact Centre will with
immediate effect include police CCTV operators being tasked via police incident management system
(“Webstorm”) to ‘scan’ for water safety equipment at the location of an incident, as part of the initial
response where it is believed someone has entered the sea and is thought to be in danger. The wording
that has been introduced as an automated prompt is ‘In incidents where a person has entered the water,
on shore or inland, where there is a CCTV view, the identification of life saving equipment, such as throw
lines, should be highlighted to attending officers/staff and members of the public who may have called
on 999.’

As mentioned previously, Sussex Police has a representative on The Brighton & Hove Coastal Water
Safety Forum (BHCWSF). There are attendees at the forum from various agencies including local council,
seafront office, local policing and local business representatives.

Sussex Police is not the lead in this partnership activity but is an active forum member and will be fully
supporting the summer ‘Keeping safe campaign’ which includes water safety advice, highlighting the
dangers of entering the sea when under the influence of drink/drugs or in adverse weather conditions.
Local businesses, particularly those involved in the night-time economy are also engaged with this
campaign and whilst they are members of the BHCWSF, they are also present during Police and partner
briefings as part of our night-time economy response,

A copy of this report has been shared with the Brighton & Hove seafront office manager for his
information and comment.

lf there are follow-up questions about this response, please come back to T/ACC May and | will do my best to
resolve them.

Thank you again

Yours sincerely

T. Assistant Chief Constable

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