Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0438, written 16 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2019 |
|---|---|
| Reference | 2019-0438 |
| Deceased | Henry Campbell-Byatt |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
,
Managing Director,
The Peligoni Club,
49 A Goldhawk Road,
Hammersmith,
London.
W12 8QP
1
CORONER
I am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London
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 the 29th and 30th October 2019, evidence was heard touching the death of Henry
Huw Duncan Campbell Byatt. On the 6th August 2017, Harry was free-diving in the sea
off Zakynthos in Greece when he sadly drowned.
Medical Cause of Death
1 (a) Drowning in seawater
How, when, where Harry came by his death:
On 6/8/2017 at around midday, Harry went free diving in deep water (around 30 m) off
the coast of Zakynthos in Greece. He failed to resurface. After around 20 mins he was
rescued and CPR started. This was sadly unsuccessful. He was recognised as life
extinct at the local hospital.
Conclusion of the Coroner as to the death:
Accident
4
Extensive evidence was taken in court. In summary:
Harry had been freediving for sport using equipment borrowed from a friend during a
break from work at the Peligoni Club. A friend accompanied him as a watcher. He was
seen to take increasingly deep dives with no difficulty. His friend retreated to the pontoon
nearby whilst he performed one more dive. Sadly he did not resurface and the alarm
was promptly raised. His body was spotted deep down on the sea-bed floor and rescue
attempted by freediving, but this was unsuccessful due to the depth. SCUBA equipment
was sourced from a local port, and he was rescued and given resuscitation. His rescuer
risked his own life to bring him up.
The seawater in this area becomes very deep very quickly. Staff regularly swim, snorkel
and free dive in this area, albeit to lesser depths that than undertaken by
. Rescue
from greater than 10m depth is very difficult and would require SCUBA equipment. The
sea quickly becomes more than 30 m deep, when even rescue by SCBA becomes very
dangerous.
The resort had a watchtower system in place at the time to monitor craft out on the
water, however it could not be established who was on duty in the watchtower at the
material time. Swimmers are not regularly observed whilst in the water.
Concerns of the Coroner:
5
1. That the Peligoni Club should consider instructing an appropriate expert to
assess whether the club should have on site equipment (SCUBA) and staff
that would allow them to effect deep-water rescue.
2. That a buoy and line should be recommended for the use by all swimmers,
including staff, who swim in an area of the sea more than 10 m deep.
3. That the system for watchtower manning should include a sign/sign out
system.
4. That an appropriate watching system for swimmers as well as sea-craft be
put in place.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR 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. 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 :
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
16th December 2019
Professor Fiona J Wilcox
HM Senior Coroner Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
Honorary Professor QMUL School of Medicine and Dentistry
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