Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0176, written 14 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2020 |
|---|---|
| Reference | 2020-0176 |
| Deceased | Yugal Limbu |
| Coroner | Sonia Hayes |
| Coroner area | Central and South East Kent |
| 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 THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer, Kent County Council 2. Chief Executive Officer, Ashford Borough Council 1 CORONER I am SONIA MARIE HAYES, assistant coroner, for the coroner area of Central and South East Kent. 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 23 March 2020 I commenced an investigation into the death of YUGAL LIMBU, then aged 34. The investigation concluded at the end of the inquest on 22 June 2020. The conclusion of the inquest was ACCIDENT, Yugal was found deceased in the River Stour alongside Bowens Field, Ashford, Kent on 9th March 2020 by Kent Police and Kent Search and Rescue. He was last seen on CCTV at 01:07 on his way home and was intoxicated. On the balance of probabilities he fell into the River Stour from Victoria Way and suffered a rapid cardiac arrest, the medical cause of death being SUBMERSION. 4 CIRCUMSTANCES OF THE DEATH On 6th March 2020 Yugal Limbu met with friends and family after work at a local restaurant and was drinking. He became separated from his family on the way home and was last seen on CCTV at 01:07on 7th March 2020 walking in the direction of his home and this would take him through Victoria Park, he was intoxicated. He did not return home and his family reported him missing on 7th March. The search concluded when he was recovered from the River Stour alongside Bowens Field, Ashford, Kent. It is likely that he fell into the River Stour in the vicinity of the footbridge where the path meets the river at Victoria Way. There was no evidence to suggest that any other person was involved in his death. 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 could 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) Victoria Park is well used by the public including at night and Kent Police raised a concern at the inquest hearing that there is an area by the footbridge where the path meets the river at Victoria Way, Ashford that is a hazard to the public. There is a clear gap and a sloped surface, and evidence from Kent Police is that this is dangerous for those using the path in diminished daylight or at night. (2) This matter has been drawn to the attention of Ashford Borough Council and Kent County Council following the inquest hearing and it is unclear which authority has responsibility for the area. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you, respectively, 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 9th November 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 Chief Coroner and to Kent County Council and Ashford Borough Council. I have also sent it to family of Yugal Limbu and Kent Police who may find it useful or of interest. 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 14th September 2020 2
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