Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0121, written 28 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 | 28 May 2020 |
|---|---|
| Reference | 2020-0121 |
| Deceased | Gillian Davey |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| 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.
Information Classification: CONFIDENTIAL ANNEX A - REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Gillian Louisa DAVEY, deceased Michael PENDER, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Grant Shapps, MP, Secretary of State for Transport; 2. Mr B Johnson, Chief Executive, Maritime & Coastguard Agency; 3. Mr M Dowie, Chief Executive, Royal National Lifeboat Institute. 1 CORONER I am Mr Andrew Cox, Acting Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 On 28 May 2020, I commenced an investigation into the deaths of Gillian Davey, aged 17 and Michael Pender aged 63. The investigations have not yet concluded and the inquests have not yet been heard. 4 CIRCUMSTANCES OF THE DEATH On 25 May 2020, Miss Davey was out with her family on a pleasure craft that was returning to Padstow on the north Cornish coast. The craft was struck by a wave and capsized, trapping Miss Davey underneath. Initially, tapping could be heard through the hull but by the time the coastguard arrived and Miss Davey was removed, she could not be resuscitated. Also on 25 May 2020, Mr Pender was swimming in the sea off Treyarnon Bay, again on the north Cornish coast, when he appears to have been caught in a rip current. He was rescued from the sea but could not be resuscitated. 5 CORONER’S CONCERNS During the course of the investigations, my inquiries 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. – These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach. 1 Information Classification: CONFIDENTIAL How this state of affairs arose will be a matter for the future. My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing. I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity. Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisations 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, namely by 26 July. I, the coroner, may extend the period. There is, however, a pressing need for this situation to be addressed immediately and I ask that, collectively, you give it your urgent attention. 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: Ms K Kennally, Chief Executive, Cornwall Council; Mr I Arrow, HM Senior Coroner, Plymouth, Torbay and S Devon; Mr P Spinney, HM Senior Coroner, Exeter and Greater Devon. I am copying this letter to my two coroner colleagues as I understand that the beaches across the whole of Devon were and remain similarly unguarded. 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 28/05/2020 Andrew Cox Acting Senior Coroner – Cornwall & the Isles of Scilly Coroner’s Area 2
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