Michael Pender

Bay 2/03 
Spring Place 
105 Commercial Road 
Southampton 
SO15 1EG 

Tel:        +44 (0)20 3817 
Email:    

@mcga.gov.uk 

Your ref: 
Our  ref:

12841 / 12844 
CE 10/2020 

2 September 2020 

Mr Andrew J Cox 
Acting Senior Coroner for Cornwall and Isles of Scilly 
The New Lodge 
Newquay Road 
Penmount 
Truro 
TR4 9AA 

By email only: cornwallcoroner@cornwall.gov.uk 

Dear Mr Cox 

Thank  you  for  your  letter  of  22  June  to  Brian  Johnson  about  the  tragic  deaths  of 
Gillian Davey  and  Michael  Pender.  I  am  replying  because  I  can  be  the  formal 
representative of the Maritime & Coastguard Agency should you call us to the inquests. 
This statement is in addition to the correspondence 
 sent you on 5 June 
replying  to  your  letter  of  29  May  2020,  receipt  of  which  was  acknowledged  by 
 from your office on 5 June and I attach that reply to this statement, for ease 

of reference.   

The Department for Transport and the Maritime & Coastguard Agency have an interest 
in maritime safety generally because we want to see fewer accidents and less demand 
on  the  emergency  services  that  we  coordinate  to  respond  to  search  and  rescue 
missions. That is why we promote initiatives such as the annual Maritime Safety Week 
alongside  partner  organisations  and  we  use  our  social  media  and  other  channels  to 
communicate  safety  campaigns  and  messages.  We  do  not  have  any  statutory  or 
specific responsibilities for beach safety. 

After the deaths at Camber Sands in 2016 and the helpful observations from Mr Craze, 
the East Sussex Coroner, the Maritime & Coastguard Agency, working closely with the 
wider membership of the National Water Safety Forum, commissioned a  review from 
an independent lawyer. We asked him to undertake research to form a view of beach 
safety in terms of legal responsibilities and to make recommendations. 

The research was completed by Dominic Watkins at DWF who took time to test out his 
thinking  with  a  wide  range  of  stakeholders.  A  review  was  completed,  and 
recommendations made. One immediate action, to update a Beach Safety Guide that 
was  originally  published  in  the  1990s,  was  completed  quickly  by  the  Maritime  & 
Coastguard Agency. The Guide provides a framework for beach owners to use when 
considering risks to the public at their beaches and advice on mitigations that might be 

 
 
 
 
 
 
 
 
 
 
 
                                                      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 used  to  address  any  risks.  We  worked  with  the  Royal  Society  for  the  Prevention  of 
Accidents and the RNLI to develop additional information published in June this year 
providing advice on maintaining the safety of the public and staff on beaches during a 
pandemic. We particularly welcomed the support of the Local Government Association 
who made the guidance available to their local authority membership. 

We recognised that the remainder of the Review’s recommendations were wide-ranging 
and would need much more detailed discussion and consideration across many interest 
groups and government Departments. We had planned to make the Review public at a 
National Water Safety Forum event in November 2019 organised by the Royal Society 
for the Prevention of Accidents. Ministers were scheduled to introduce the Review and 
our plan was to use the occasion to start a wider consideration of the policy matters it 
contains. However, at the beginning of November the Prime Minister called a General 
Election  for  12  December  2019.  It  is  a  convention  within  Government  that  all  but 
essential  policy  announcements  are  deferred  during  the  pre-election  period,  which 
meant that the Minister was no longer able to attend the Safety Conference and start 
the wider discussions. 

Ministerial appointments and portfolios were confirmed at the end of February 2020 and 
soon after new Ministers had been briefed about the most pressing issues that needed 
to  be  at  the  top  of  their  priorities,  attention  necessarily  focused  on  the  coronavirus 
pandemic. The opportunity to consider the independent review has now been taken and 
we  intend  to  publish  it  on  gov.uk  as  soon  as  possible.  Ministers  are  seeking  a  wider 
debate about the merits of the remaining recommendations and we will be discussing 
these with stakeholders with a view to gauging opinion on possible next steps.   

However, you will understand that this will not be a quick process and it will take time to 
come  to  any  firm  conclusions.  Within  his  report  the  author  is  very  clear  that  “while 
commissioned  by  the  MCA,  it  is  important  to  stress  that  this  Report  and  its 
findings are entirely independent from the MCA”. 

There are many stakeholders with an interest in beach safety and finding absolute legal 
clarity about responsibilities may be difficult. The Ministry of Housing, Communities and 
Local Government has an interest in supporting local authorities, many of which will be 
the  notional  “owner”  of  much  of  the  United  Kingdom’s  11,500  miles  of  coastline  and 
many of our 1,320 beaches. Other beaches will be privately owned or owned by other 
major landowners such as the National Trust and the Crown Estates. 

As  part  of  the  response  to  the  current  pandemic,  the  Cabinet  Office  have  brought 
together parts of the machinery of government with an interest in beach safety and this 
may be a useful forum to consider some of the challenges set out in the Review. There 
may also be a role for the National Water Safety Forum and its constituent members. 
Indeed,  the  Forum  has  already  brought  together  a  compendium  of  existing  helpful 
advice and guidance to support beach owners in their efforts to understand and mitigate 
safety risks. 

We  believe  it  is  too  soon  to  judge  what  conclusions  those  wider  discussions  and 
considerations  might  lead  to  and  whether  new  legislation,  greater  collaboration  or 
further guidance to support beach owners might offer the most effective approach.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 Fundamentally and ultimately, however, people have a personal responsibility for their 
own  safety  in  and  around  water  and  on  beaches.  Landowners,  local  authorities  and 
others can provide safety information including signage and public rescue equipment, 
but it is individuals taking responsibility for their own safety and actions that will keep 
most people safe. Even where beach owners carry out a risk assessment and conclude 
that they can support safety by providing a lifeguarding service, whether from the RNLI 
or another provider, those services will not operate 24 hours a day and always cover 
just a limited area of each beach. Deployment will also be seasonal to take account of 
the  times  of  year  when  the  risk  is  judged  to  be  at  its  highest.  The  provision  of  a 
lifeguarding service is not, and can never be, an absolute guarantee of safety.  

For our part in the Maritime & Coastguard Agency we will continue to work with partners 
on  safety  campaigns  and  messaging  using  social  media  and  paid  advertising. At  the 
moment we are engaged in a joint campaign with the RNLI to encourage coastal safety, 
discourage people from using inflatables at the beach, and to remind them that if they 
do get into difficulty then they should call 999 for the Coastguard. 

We are ready of course to support you with your upcoming inquests. I will attend in my 
role as Assistant Director with Her Majesty’s Coastguard. I will be able to explain our 
search and rescue operations generally and the specific actions in the two deaths you 
are examining. I will also be able to set out what is happening in relation to the wider 
review. 

Yours sincerely 

Assistant Director  
Her Majesty’s Coastguard Policy & Standards

Bay 3/13 
Spring Place 
105 Commercial Road 
Southampton 
SO15 1EG 

Mr Andrew J Cox 
Acting Senior Coroner for Cornwall and Isles of Scilly 
The New Lodge 
Newquay Road 
Penmount 
Truro 
TR4 9AA 

By email only: cornwallcoroner@cornwall.gov.uk 

Tel: 
E-mail: 

+44 (0)20 3817 

@mcga.gov.uk 

Your ref: 
Our  ref:

AJC/LJB 
CE 10/2020 

5 June 2020 

Dear Mr Cox 

Thank you for your letter of 29 May, enclosing your Regulation 28 Prevention of Future 
Deaths  report  following  the  recent  deaths  in  Cornwall  of  Gillian  Davey  and 
Michael Pender.  I note that your investigations have not yet concluded and the inquests 
into the deaths have  not been heard.  On a point of fact related to Section 4 of your 
report, it was the RNLI lifeboat that was on scene for the incident involving Miss Davey 
rather than the Coastguard – our role was to coordinate the tasking of the lifeboat. 

In your report, under Section 6, you say that the Department for Transport, the RNLI 
and  the  Maritime  and  Coastguard Agency  (MCA)  have  the  powers  to  take  action  in 
respect  to  providing  a  lifeguard  service  on  beaches  in  Cornwall,  to  help  prevent  the 
future loss of life.  The MCA, which includes Her Majesty’s Coastguard, is an executive 
Agency of the Department for Transport.  I am therefore replying on my own behalf, and 
also  on  behalf  of  the  Secretary  of  State  for  Transport,  the  Right  Honourable 
Grant Shapps MP.  The MCA has a responsibility to respond to calls for assistance as 
the emergency responder with the remit for search and rescue at the coast and at sea. 
Our role is to coordinate  the  emergency response drawing from the matrix of search 
and rescue resources that are available and appropriate.  However, we have no remit 
for beach safety or the provision of  lifeguarding.  I should also make  it clear that the 
RNLI has no legal obligation or duty to provide either lifeguards or lifeboats. 

Alongside  the  RNLI  and  other  sea  safety  charities,  we  promote  safety  messages 
including specific campaigns aimed at the general public for when they go to the beach.  
Those messages are designed to help save lives and to reduce the call on resources.  
The relevant beach owner, which can be a local authority, sometimes the National Trust 
and many private owners have the responsibility to carry out risk assessments covering 
public use of beaches and then to mitigate the risks they identify.  To help landowners 

 
 
 
 
 
 
 
 
 
                                                      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 with  responsibilities  for  beach  safety  with  those  risk  assessments  we  produced 
guidance on Managing Beach Safety1. 

One way to manage risks is to arrange for a lifeguarding service, which may well be 
organised  under  contract  with  the  RNLI.    As  a  result  of  the  lockdown  across  the 
United Kingdom from late March 2020, the RNLI was unable to recruit and train their 
prospective community of lifeguards for the 2020 season in a way that was consistent 
with social distancing rules, and neither could they enter into arrangements with local 
authorities and landowners as they would in a normal year.  

I  can  tell  you  that  the  RNLI  is  working  with  local  authorities  and  others  to  steadily 
ramp-up  their  capability  to  provide  a  beach  lifeguarding  service.    Already  at  least 
18 beaches have RNLI lifeguards.  Plans are in place to have lifeguarding services at 
as  many  beaches  as  is  feasible  in  the  current  circumstances,  including  many  in  the 
South  West.    The  RNLI  will  make  a  public  announcement  with  more  detail  over  the 
coming weeks.  

Others  such  as  Surf  Life  Saving  Great  Britain  are  also  doing  their  best  to  provide 
services  ranging  from  beach  wardens  to  fully  trained  lifeguards.    The  nature  of  that 
provision, whether it uses purely volunteers or paid-for staff, and the hours of availability, 
will vary from location to location.   

For our part, given that the RNLI and similar organisations may not have lifeguards on 
beaches, we are sending more HM Coastguard vehicle patrols to known safety hotspots 
for  surveillance purposes, keeping a look out for any incidents at the coast enabling a 
swift response for search and rescue, should that be needed.  

I am copying this response to the Chief Executive of the RNLI, Mark Dowie. 

Yours sincerely 

Chief Executive 

1 https://www.gov.uk/government/publications/managing-beach-safety

Mr Andrew Cox 
Acting Senior Coroner  
Coroner for Cornwall & the Isles of Scilly 
The New Lodge 
Newquay Road 
Penmount 
Truro 
TR4 9AA 

By email only: cornwallcoroner@cornwall.gov.uk 

5 June 2020 

Dear Mr Cox, 

I write with regard to the recent deaths of Gillian Davey and Michael Pender in Cornwall, and your report on 
Action to Prevent Future Deaths issued pursuant to Regulation 28 (‘the Regulation 28 Report’) dated 28 May 
2020. I note that your investigations have not yet concluded and the inquests into the deaths have not been 
heard. 

Before I respond to your request for details of the planned RNLI lifeguarding service, there is a preliminary 
matter I need to raise. As you are aware, I have been copied into the letter to you of today’s date from Brian 
Johnson,  Chief  Executive  of  the  Maritime  and  Coastguard  Agency.  I  entirely  agree  with  and  support  the 
contents of his letter to you. 

I appreciate your concerns about the prevention of future deaths. Further, I also appreciate that in accordance 
with Chief Coroner’s Guidance No. 5, you may issue a Regulation 28 Report before an inquest is concluded. 
However, in this instance I believe the Regulation 28 Report is premature and has been made without the 
benefit of all the relevant information; this includes the fact it is the landowner, not the RNLI, who has the 
responsibility to carry out risk assessments covering the public use of beaches, and then to mitigate the risks 
they identify by, amongst other things, providing a lifeguarding service. 

As you set out in paragraph 5 of your report, your request is based upon the fact you believe that, unless 
lifeguarding services are back on beaches, there will inevitably be a further loss of life. This pre-supposes that 
both deaths were caused by a lack of lifeguards, which of course will require an inquest to determine.  

Further, and importantly in the case of Gillian Davey, the incident did not happen next to a beach. Accordingly, 
no RNLI staff would have witnessed the incident. Instead, as was the case, a RNLI Lifeboat would have been 
tasked by HM Coastguard to attend. I imagine this will be a matter for evidence. 

I note in your report at paragraph 4 you state the Coastguard arrived to perform the rescue and Miss Davey 
was removed. In fact, it was the RNLI which carried out this rescue.  

As is set out above, I consider it very likely the RNLI will be required to provide you with evidence to allow you 
to fulfil your role. It is for this reason that, insofar as it relates to the RNLI, I consider the Regulation 28 Report 
to be premature. As you will be aware, paragraph 12 of the Chief Coroner’s Guidance No. 5 states that a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 report will normally be made after an inquest is concluded. This is because a pre-condition to making a report 
(Regulation 28 (3)) is: 

‘A report may not be made until the coroner has considered all the documents, evidence and information 
that in the opinion of the coroner is relevant to the investigation’. (emphasis added) 

The RNLI has not yet provided you with any documents, evidence or information. I hope that once you have 
been provided with such information, you will not consider it necessary to issue a report.  

In these circumstances, I would respectfully ask that you withdraw your report; certainly, insofar as it relates 
to the RNLI. 

Notwithstanding the RNLI’s position on the Regulation 28 Report, I appreciate and understand your concerns 
in relation to beaches. As you may be aware, an objective of the RNLI is ‘to end preventable loss of life at 
sea’. It is clear we share your concerns. I have set out below some information in relation to the current plans 
for readiness, to give you assurance the RNLI is doing all in its power to provide a lifeguard service on many 
beaches across the UK, including on beaches in Cornwall. You should also note that many beaches, possibly 
the  majority,  never  have  lifeguard  services,  and  many  other  organisations  beyond  the  RNLI  provide 
lifeguarding services on beaches around the UK coast. 

Our original plan was to have lifeguard patrols on 70 beaches this summer. It was a conservative plan and 
made and announced when many things were still unknown. We now have a better idea of the journey out of 
lockdown for all parts of the UK, understand the new regulations with which we must comply as an employer 
and  service  provider  and,  most  importantly,  feel  we  can  properly  manage  the  risks  associated  with 
coronavirus. We were on 18 beaches last weekend, 8 of which are in Cornwall, and we are revising our original 
plans and exploring which additional beaches we can lifeguard this summer. To this end, we are working hard 
with 55 landowners and local councils to ensure as many beaches as possible will have RNLI lifeguard cover. 
With so many local landowners to work with, and so many dependencies, it will take time to confirm individual 
beaches and timings, but we will make public announcements with more detail over the next few weeks. 

I have only set out the plans for the current and future rollout of lifeguarding, but I can provide information as 
to the reasons why RNLI lifeguarding services were not on the Cornish beaches at the time of the two tragic 
deaths, along with some of the  other preventative steps that had, and will continue to be taken, including 
widespread media messaging and signage. This can be provided in due course for the inquest. 

I hope this provides the information you require. I can assure you that everyone at the RNLI; its leadership, 
staff, volunteers and supporters, cares passionately about our purpose  – saving lives at sea. We have for 
nearly 200 years and we always will. 

Yours sincerely, 

Chief Executive