Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0028, written 13 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2020 |
|---|---|
| Reference | 2020-0028 |
| Deceased | Martin Ellis |
| Coroner | Mary Hassell |
| 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
Martin Edward ELLIS (died 16.08.19)
THIS REPORT IS BEING SENT TO:
1.
High Commissioner for Saint Lucia to the UK
High Commission of Saint Lucia
1 Collingham Gardens
Kensington
London SW5 0HW
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
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 13 September 2020, I commenced an investigation into the death of
Martin Edward Ellis, aged 69 years. The investigation concluded at the
end of the inquest earlier today. I made a narrative determination, a copy
of which I attach.
4
CIRCUMSTANCES OF THE DEATH
Mr Ellis was electrocuted at the Sir John Compton Dam in Saint Lucia,
while holidaying there with his family.
The Water and Sewerage Company, WASCO, is the public sector water
funded and managed by central government,
utility company,
responsible for water supply on the island. This includes responsibility
for the dam.
1
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. The dam is apparently not open to members of the public, but Mr
Ellis and his family were able to visit it with ease, not even knowing
that it was restricted, still less having access prevented.
2. I found at inquest that the only warning sign was old, in poor repair
and covered by foliage, so could not be seen.
3. I accepted evidence in court that construction workers did not
warn the family off visiting the dam, but rather gave them
directions on how to get there and where to park their car.
4. The electrocution was caused by exposed live wiring in a
galvanised metal conduit.
I understand that the Chief Electrical Officer visited the site in the
days after Mr Ellis’s death and that the Ministry of Infrastructure,
Ports, Energy and Labour is responsible for the Saint Lucia
investigation. However, six months after Mr Ellis’s death, no
explanation has been provided to his family or to HM Senior
Coroner for Inner North London, as to why there was an exposed
live wire. Despite repeated requests, neither Mr Ellis’s family nor
I have been provided with a copy of the Chief Electrical Officer’s
report.
5. The dam was built in 1996. I do not know whether the unsafe
wiring is a result of a lack of appropriate building regulations
enforcement. I do not know whether other constructions built at
around the same time are unsafe.
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 13 April 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 & Wales
, wife of Martin Ellis
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
13.02.20
3
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