Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0399, written 22 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2019 |
|---|---|
| Reference | 2019-0399 |
| Deceased | Jonathan Adebanjo |
| Coroner | Edwin Buckett |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Jonathan Jesutofumi Adebanjo (died 24.7.2019)
THIS REPORT IS BEING SENT TO:
Mr Will Tuckley
Chief Executive
London Borough of Tower Hamlets
Town Hall
Mulberry Place
5 Clove Crescent
London
E14 2BG
1
CORONER
I am: Edwin Buckett
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street, London E14 0AE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
Regulations 28 and 29.
3
INVESTIGATION and INQUEST
On the 30th July, 2019 an investigation was opened by Assistant Coroner
Bourke into the death of Jonathan Jesutofumi Adebanjo who died aged
23, on the 24th July, 2019 at Shadwell Basin, London, E1.
The investigation progressed to an inquest which I conducted on the 20th
November, 2019. I made a determination at the conclusion of the inquest
that the deceased had drowned as a result of an accident whilst
swimming in Shadwell Basin.
4
CIRCUMSTANCES OF THE DEATH
1
1. On the 23rd July, 2019 at about 5.45pm, the deceased used a
ladder to descend into the water at Shadwell Basin in order to
swim.
2. After a short while he sank below the water line and drowned.
3. His body was not found until the morning of the 24th July, 2019.
4. The deceased was not local to the area and the day he died was
the first time he and his friends had visited the area.
5
CORONER’S CONCERNS
During the course of the inquest, the following 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.
Evidence was given by the police at the Inquest that:
1. The London Borough of Tower Hamlets is responsible for the
area.
2. Although swimming is actually prohibited at the location, people
do swim there in hot weather.
3. The water in Shadwell Basin is murky with poor visibility
underwater with rubbish and discarded items below the surface.
4. There is an undercurrent at the Basin.
5. The area where the deceased was swimming was not covered by
CCTV.
6. The fixed signs which indicate that swimming is prohibited are
fairly small and can be missed if the area is busy.
I am concerned that:
(a) The signs indicating that swimming is prohibited at the location
should be larger and more obvious;
(b) The content of the signs should indicate the reason why
swimming is dangerous, namely the poor visibility, the presence
of the undercurrent and the presence of rubbish and discarded
items below the surface.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
2
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 24th January, 2020. 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England and Wales;
[address withheld]
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
DATE 22nd November, 2019 SIGNED BY
ASSISTANT CORONER EDWIN BUCKETT
3
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