Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0021, written 25 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jan 2022 |
|---|---|
| Reference | 2022-0021 |
| Deceased | Anthony Rode |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Accident at Work and Health and Safety related deaths · Other 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 . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Great Yarmouth Borough Council Town Hall Great Yarmouth Norfolk NR30 2QF Clerk for Parish Council 79 Seafield Road North Caister-on-Sea Great Yarmouth Norfolk NR30 5LF 1. CORONER I am Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 13/08/2021 I commenced an investigation into the death of Anthony David RODÈ aged 74. The investigation concluded at the end of the inquest on 24/01/2022. The medical cause of death was: Hypoxic Brain Injury Out of Hospital Cardiac Arrest Spinal Fractures Following a Fall 1a) 1b) 1c) 1d) 2 The conclusion of the inquest was: Accident. 4. CIRCUMSTANCES OF THE DEATH Mr Rodè was a volunteer for the Coastwatch Institution, based at Second Avenue, Caister On Sea. On 24 July 2021 Mr Rodè used his own strimmer to cut grass on sand dunes next to the office, which had grown to such a height it was restricting the view from the hut down the beach. Whilst strimming the grass, Mr Rodè fell down the bank onto the concrete path below sustaining injuries which led to 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. There is a dispute between Great Yarmouth Borough Council and Caister-On-Sea Parish Council as to who is responsible for the stretch of land where Mr Rodè was strimming the grass. 2. Caister-On-Sea Parish Council state that the bank is part of the sea defences and so is the responsibility of the Great Yarmouth Borough Council. 3. Great Yarmouth Borough Council state the land belongs to the Parish Council and so is their responsibility. 4. As a result, neither organisation has taken responsibility for this section of coastline and the grass on the dunes has grown to such a height as to obscure the view of the Coastwatch volunteers along the beach. 5. Accordingly, the Coastwatch volunteers are unable to properly carry out their role to provide the “eyes and ears” along the coast and to assist in the protection and preservation of life at sea and along the coastline. In addition, in this case, it has resulted in a volunteer making the decision to cut the grass himself in circumstances when it was not safe to do so 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 21 March 2022. 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: I have also sent it to RoSPA who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9. Dated: 25 January 2022 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH
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.
Jacqueline Lake Senior Coroner for Norfolk Norfolk Coroner Service By email 18 March 2022 On behalf of Great Yarmouth Borough Council and Caister-on-Sea Parish Council Dear Mrs Lake, Prevention of future deaths report – Anthony David Rode We acknowledge your report of 25 January 2022 into the circumstances surrounding the death of Mr Rode, and your points in relation to the ownership and maintenance of land. We would first like to offer once again our condolences to Mr Rode’s family and friends, and to restate our appreciation for his effort and those of his fellow Coastwatch volunteers in helping keep people safe when visiting the seaside. Mr Rode’s dedication in regularly travelling from Mundford is particularly worthy of respect. Land ownership Your report discusses the ownership of the land where Mr Rode intended to carry out grass strimming. Although some areas of coastal land are registered, including the nearby toilet block, most of the land in this area is not registered. As you may be aware, although the Land Registry was established in 1862, compulsory registration of all land transactions is a relatively recent requirement and has been introduced in stages up until 1990, and in broad terms is only triggered when land changes ownership. As a result around 13% of land in the UK is not publicly registered and ownership is indicated only by private deeds. This includes much of the coastline, and the land involved in this case. The borough and parish councils have examined our own records and enquired with the Land Registry, and we have been unable to find any definitive proof of who owns this particular land, and nothing to indicate that it is in the ownership of either council. We would therefore seek to clarify that there is no “dispute” as to ownership of the land. As to responsibility for maintenance, the section below explains the position. Historic map records indicate that the land was previously part of the route of the Eastern and Midlands Railway, eventually passing into British Railways with nationalisation in 1948 and eventual closure in the 1950s. It is unclear where ownership now lies. We believe the likeliest current owner is one of the successor bodies to the British Rail Board but we have been unable to definitively confirm this. Maintenance and coastal protection Notwithstanding questions of ownership, the Coastal Protection Act 1949 places certain duties and powers with local authorities whose area adjoins the sea. Great Yarmouth Borough Council primarily www.great-yarmouth.gov.uk - Town Hall, Hall Plain, Great Yarmouth, Norfolk, NR30 2QF Page 1 of 2 manages these responsibilities through our property team and with the advice of Coastal Protection East, a joint endeavour with North Norfolk and East Suffolk district councils. There is a shoreline management plan that governs the approach to the area, balancing environmental protection and human and economic impacts. The marram grass and dune areas along the coast play an important part in this ecosystem, and under the CPA it may be an offence to carry out work that affects them without the permission of the coastal protection authority. We understand and appreciate that Mr Rode was likely not aware of this and that his motivation was to aid his follow volunteers in monitoring the coastline. We are not aware that he or Coastwatch sought advice on trimming the marram grass, but if this had been requested we would have been able to explain that our approach is to allow natural growth in this area to supplement the nearby man-made sea defences and to support the local ecology. This would have allowed further discussions with Coastwatch on obtaining a better vantage point through other means, allowing their work to continue but without affecting the natural defences provided by the marram grass. Education and prevention We recognise that individuals and organisations, while acting with the best of intentions, may only have a partial understanding of the interlocking issues around coastal management. This, in turn, may lead them to taking direct action which would be outside of our established shoreline management plan. To help reduce the potential for this to happen in future, Great Yarmouth Borough Council and Caister-on-Sea Parish Council have agreed to take the following steps to increase public awareness of these issues: • Discussion with parish councils within the borough at our Parish Liaison Meeting on 28 March 2022, encouraging local publicity through village newsletters and similar publications • Writing to and meeting with organisations and businesses, such as Coastwatch, that have a presence close to the shoreline to explain the operation of our shoreline management plan, including the need to seek permission from the coastal protection authority before carrying out any works, and how we can work together with them to support their operations • A social media campaign to promote understanding of the shoreline management plan, and to discourage independent activity • Working with our Coastal Protection East partners to encourage similar steps to increase understanding of the same within their districts. We will also continue to investigate the ownership of the land although for the reasons stated above we do not believe this was necessarily material in this case, as the requirements of the CPA and the shoreline management plan apply irrespective of ownership. We would be happy to provide any further information that may assist you. Chief executive, Great Yarmouth Borough Council Clerk, Caister-on-Sea Parish Council www.great-yarmouth.gov.uk - Town Hall, Hall Plain, Great Yarmouth, Norfolk, NR30 2QF Page 2 of 2
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