Prevention of Future Deaths reports · 2019
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 report | 10 Apr 2019 |
|---|---|
| Reference | 2019-0127A |
| Deceased | David Dooley |
| Coroner | Gilva Tisshaw |
| Coroner area | Brighton and Hove |
| Category | Police 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.
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
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.
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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