Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0197, written 9 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2021 |
|---|---|
| Reference | 2021-0197 |
| Deceased | Nicholas O’Brien |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southhampton |
| Category | Other related deaths · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 British Kite Surfing Association 1 CORONER I am Jason PEGG, Area Coroner for the area of Hampshire, Portsmouth and Southampton 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 and INQUEST On 7th July 2020 I commenced an investigation into the death of Nicholas James O'BRIEN aged 50. The investigation concluded at the end of the inquest on 09 June 2021. The conclusion of the inquest was: I a Delayed Effects of Head and Neck Injury I b I c II 4 CIRCUMSTANCES OF THE DEATH The deceased died on 30th June 2020 at Southampton Hospital, Tremona Road, Southampton, Hampshire. The deceased suffered traumatic injuries to his head and neck whilst kite-surfing off Calshot Beach, Hampshire on 28th June 2020. A gust of wind caused the deceased to lose control of his kite causing the kite rigging to became entangled in a radio transceiver fitted to the deceased's helmet rendering the deceased unable to depower his kite in consequence of which the deceased was pulled through the sea and across a spit of ground by his helmet. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: The deceased was under kite-surfing instruction on 28th June 2020. A radio intercom device used to assist with instructing the deceased had been attached to the helmet worn by the deceased using an adhesive pad provided by the United States based manufacturers of the device. The kite rigging became entangled around the device preventing the deceased from depowering the kite and causing the deceased to be dragged through the water by his helmet. The device remained in situ. The device was not secured in such manner that it was pulled off when the kite rigging became entangled around the device and exerted forces upon it. This concern could apply to devices similarly affixed to helmets, for example, action cameras and awareness of such concern should be addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you your organisation 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 4th August 2021. 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 the following Interested Persons: – Brother of the deceased 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 Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Dated: 09 June 2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
RECOMMENDATIONS TO BKSA SCHOOLS USING BB-TALKIN HEADSETS OR SIMILAR DEVICES INCLUDING ACTION CAMERAS WHEN DELIVERING COACHING AND TRAINING COURSES. These recommendations form the bases of giving additional guidelines and information to BKSA schools to raise awareness of the hazards and limitations of using headsets and action cameras when delivering teaching and coaching sessions. 1. Always follow the manufactures fitting instructions when attaching devices to any kite surfing helmet. 2. Always use a compatible helmet to the device you are using (normally listed by manufacturer) 3. Always use the provided sticky pads and position as directed by the manufacturer. 4. Do not under any circumstance permanently fit / glue or attach any part of the device to the side or front of the helmet using cable ties / screws / permanent fixings. 5. Always check the device and helmet is fit for use and in good working order prior to the teaching or coaching session commencing. 6. Make student aware that although unlikely there is a small chance that student lines could get entangled around headset / action camera (the point is to raise awareness) CHECK / REINFORCE FOLLOWING • Correct fitting of helmet to student • Devices are positioned and secured correctly as per manufactures guidelines • Student - Importance of concentrating on flying the kite during the session when instructor is talking over the mic • Do not try and adjust head set whilst flying the kite, keep both hands on the bar • If you need to adjust the headset, bring the kite down to the side of the wind window and land prior to adjusting. • Correct positioning of bar and importance of line tension / bar pressure • What to do if kite lines get entangled • All safety signals as directed by instructor / coach. 7. Schools to include a specific annex as part of the Schools Safety Management Systems (SMS) outlining guidelines in using any Bb-Talkin or similar portable devices including action cameras. 8. Principal / CI to deliver in house training to staff (record) in use of and potential hazards when using portable head set devices and action cameras. (Case Study) 9. SI to check the weather forecast for the day and decide based on wind strength and session type as to whether its suitable to use the device. (F5) 10. Ensure your student / students are at a suitable level of competency to be able to safely use / get benefit from this type of device when undertaking in a lesson. 11. Head set devices / action cameras not to be used by students until min L1P4 signed off to reduce risk of line entanglement when / if body dragging. 12. Centre Principal / CI to ensure /reinforce all instructors are required to carry a suitable serrated blunt ended knife on their person during on water teaching sessions. 13. All head sets and procedures will be inspected and reviewed as part of the BKSA schools’ annual inspection.
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