Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0108, written 1 May 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2020 |
|---|---|
| Reference | 2020-0108 |
| Deceased | Barrie Copeland |
| Coroner | James Thompson |
| Coroner area | Bedfordshire and Luton |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
|__| REGULATION 28 REPORT To PREVENT FUTURE DEATHS
ecarees|
| THIS REPORT IS BEING SENT To:
1. Chief Operating Officer, TUIUK & ireland, Wigmore House, Wigmore Pace,
| Wigmore, Luton, Beds, LU2 9TN
Se om Beds, LU2 oT ne
— |
{1 | CORONER |
| | lam James E THOMPSON, assistant coroner, for the coroner area of County Durham &
| | Darlington
SSS Rib ee inn eae ah Dak en ot ed So
|2 | CORONER'S LEGAL POWERS ~
| and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
| |
| i
| | | make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
|
| | (see attached sheet)
/On oth October 2018 | commenced an investigation into the death of Barrie Crawford
| | COPELAND, 79. The investigation concluded at the end of the inquest on 27th April
|
i i 2020. The conclusion of the inquest was Accident.
i
Medical cause of death:
1a. Aspiration pneumonia
| 1b. Acute intracerebral haemorrhage
| 1c. Accidental trauma while on anticoagulation for atrial fibrillation
2. Ischemic heart disease & atrial fibrillation
| A copy of the Record Of Inquest is attached to this report.
|
| ey
Mr Copeland was a Passenger on board the Marella Discovery (operated by TU) on
| 23rd August 2018 whilst in the Broadway Show Lounge on the Ship looking for a seat to
| waich an entertainment event, he fell down a step/s, suffering a head injury which
| ultimately led to his death on 21st September 2018.
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SESS eee 8 oe
5 | CORONER’S CONCERNS |
| SS DMNER'S CONCERNS j
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| 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.
| During the course of the evidence heard at the inquest, a witness described the step/s
| Mr COPELAND fell on were covered in carpet so.as to make them difficult to recognise
| them as Steps, and difficult to differentiate the change in the floor level at the venue. The |
| lighting in the lounge can be altered and were not at the time of the accident fully lit. |
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| The MATTERS OF CONCERN are as follows. — i
| |
1
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| The inquest did not have any evidence to indicate whether the scene of the accident had
In my opinion action should be taken to prevent future deaths and | believe your
| organisation has the power to take such action.
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| a Poe eee niage ee a —
7 | YOUR RESPONSE |
| H
| You are under a duty to respond to this report within 56 days of the date of this report, i
| | namely by 25th June 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. |
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"| COPIES and PUBLICATION
{
| [have sent a Copy of my report to the Chief Coroner and to the following Interested
| Persons -
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i It
cy on behalf of the COPE |
| | 2. Messrs Slater & Gordon, solicitors o i |
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| |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
i | 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 th¢ Ghief Coroner.
| see se oursoe aa
| | ¥ S
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