Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0217, written 30 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 | 30 Apr 2019 |
|---|---|
| Reference | 2019-0217 |
| Deceased | Clive Jones |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| 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.
IAN MICHAEL ARROW Senior Coroner for Plymouth, Torbay and South Devon nein nnn renner REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Transport, Chris Grayling, Great Minster House, 33 Horseferry Road, London, SW1P 4DR 1 CORONER - lan Michael Arrow, Senior Coroner, Plymouth, Torbay and South Devon 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST Following an Investigation an Inquest opened on 4 October 2017. The findings of the Inquest Hearing on 30 April 2019 at Plymouth Coroner's Court the following was determined:- The deceased was Clive Anthony Jones. Medical Cause of Death was:- 1(a)} Drowning 1(b) i(c) ll Hypertensive Heart Disease The Conclusion of the Jury was the death was as the result of an Accident. 4 CIRCUMSTANCES OF THE DEATH On 26 September 2017 the deceased was on his own boat when the crew attempted to haul in an excessive weight within the net that had trawled. The net drum failed and accordingly an ad hoc arrangement was used which consisted of lifting the net through a higher block on to the transom but due to the weight it caused the vessel to list heavily to port. The vessel was unstable and capsized. The deceased was trapped in the wheelhouse where he drowned. His body was later recovered by Navy divers. 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) At the Inquest MAIB Inspector Mr Flegg gave evidence of various procedures and policies. Most important amongst these were the recommendations made by MAIB which were as set out in Section 5 of his report (and are annexed) that there be an independent review of the UK Search and Rescue operational capability and Her Majesty's Network Coastguard functionality. (2) To conduct a thorough review of Search and Rescue information technology systems to ensure a reliable network, ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Secretary of State have the power to ensure the recommendations are followed. | would ask you please to report to me firstly that the recommendations have been actioned and subsequently ask that you or your successor report to me once the reviews have been concluded and if a report is produced provide me please with a copy and the relevant review report. | shall be sharing both of these documents with the Chief Coroner. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 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, HB vias Inspector) and the Next of Kin| 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. Dated:- 30 April 2019 Signature IM Arrow, Senior Coroner
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.
RECEIV ED From the Secretary of State aS The Rt. Hon. Chris Grayling ee 1 8 JUN 2019 Great Minster House or lranspoor 33 Horseferry Road P HM GORONER SOTO ADR lan W Arrow Tel: 0300 330 3000 Senior Coroner E-Mail: Plymouth, Torbay & South Devon Area Web site: www.gov.uk/dtt 1 Derriford Park, Derriford Business Park Plymouth PL6 5QZ Is TH > NK Peo Thank you for your letter of 1 May, in which you enclosed a Regulation 28 Report, following an inquest into the death of Clive Anthony Jones, which includes two concerns that relate to Her Majesty’s Coastguard, part of the Maritime and Coastguard Agency (MCA). In relation to the first of your concerns about commissioning an independent review of the UK search and rescue (SAR) operational capability and functionality, | understand that an independent review will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. The Terms of Reference have been agreed and the review will include looking at the SAR operational capability, including the implementation of actions identified by both the Maritime Accident Investigation Board (MAIB) and the Irish Coastguard, following the sinking of the SOLSTICE. The outcomes from this review will be captured in a completion meeting, which is on target to take place within the MAIB recommendation timeframe. | have asked the MCA to write to you once that process is complete. The second concern recommendation, relating to conducting a thorough review of SAR information technology systems, has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May. | am aware that a full review was conducted, and the improvements identified in the network have resulted in greater reliability and resilience throughout the UK. | trust this addresses the concerns raised in your letter. Cot Sai wot Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT
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