Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0178, written 15 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jun 2022 |
|---|---|
| Reference | 2022-0178 |
| Deceased | Paul Welch |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and Isles of Scilly |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Planning Officer, Cornwall Council 2. Parish Clerk, Mylor Parish Council 3. Sailors Creek CIC 1 CORONER I am Andrew Cox, the 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 and INQUEST On 7/6/22, I concluded an inquest into the death of Paul John Welch aged 53 who died on 2/1/21. . The medical cause of death was recorded as: 1a) Massive head injury I recorded a Conclusion of an Accidental Death. 4 CIRCUMSTANCES OF THE DEATH While walking with his daughter along the foreshore at Sailors Creek, near Flushing in Cornwall on 2/1/21, Mr Welch was struck by an overhanging tree that fell out of an embankment. He suffered a serious head injury and died at the scene. The landowner had previously commissioned tree surveys to assess the risk caused by trees within striking distance of highways and footpaths in the area. Through oversight, the trees aligning Sailors Creek had been omitted from the surveys. Subsequent to the incident, the omitted trees were surveyed by Treewise at the request of Sailors Creek CIC. A number of recommendations were made to trim and thin various trees. at The trees are subject to a Tree Preservation Order. An application has been made to Cornwall Council for authority to carry out the recommended works. The inquest was advised that Mylor Parish Council has objected to the works being done and no action has been taken. The inquest heard that two individuals, Sailors Creek without lawful permission to do so. From time to time, those individuals access the foreshore where the incident involving Mr Welch occurred. Other members of the public are able also to gain access to the foreshore. Unless and until the recommended works have been carried out, there is an obvious risk to the safety of these individuals and members of the public. , remain in and 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 Information Classification: CONTROLLED The MATTERS OF CONCERN are as follows. – As set out above, the remedial works that it has been advised be carried out to the trees aligning Sailors Creek have not been undertaken notwithstanding the obvious risks to individuals present there, as evidenced by the tragic death of Mr Welch. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. Please re-consider the planning application in respect of the remedial works recommended on the trees aligning Sailors Creek. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10/8/22. 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: (1) to for their information. . I have also sent the report and (2) (3) 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 [DATE] 15.06.22 [SIGNED BY CORONER] 2
2 responses 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.
Subject: Death of Paul John Welch - Regulation 28 Report & Letter (ref: 3949493) Information Classification: CONFIDENTIAL Dear Mr Cox, AJC/LLS_3949493 Regulation 28 Prevention of Future Deaths letter I am writing to respond to the above letter dated 15th June 2022. The Council received an application from Sailors Creek CIC for works to various trees subject to Tree Preservation Order at Sailors Creek, Trevissome, Flushing on 14th January 2022. The application reference is PA22/00364. Such applications are required to provide sufficient detail for the Local Planning Authority to be clear on the extent of the works and the justification therein. In this instance, the supporting information provided with the application was not sufficiently detailed for the Local Planning Authority to determine the application. This was raised with the applicant on 9th March 2022 and further justification was requested to support the application. The Council's Tree Officer sought to meet with the applicant's arboriculturist at that time but there was a reluctance to do so and on 23rd March 2022 the applicant asked for the application to be put on hold for the time being. Following receipt of your letter the Council discussed the matter with suggested once again that a meeting on site with the relevant parties would help to bring this matter to a conclusion. A meeting was subsequently arranged for 1st August with representatives from Sailors Creek CIC, Trefusis Estate, Mylor Parish Council, Tree Wise arboricultural consultants, Cornwall Council planning and tree officers. as landowner and The Council wrote to all attendees prior to the meeting and suggested the following approach for the meeting: 1. I would recommend an agreement be reached for a systematic approach to inspection of the trees and the risk they pose. The trees should be considered by the appointed specialist in line with industry recognised tree inspection procedures (E.g. VTA) and where appropriate/necessary, a recognised tree risk management framework (QTRA, VALID, etc.) It is imperative that the surveyed evidence and risk assessment provides clear and convincing justification for any tree management proposals, proportionally to the magnitude of proposed works. 2. This review of the tree asset will enable a revised set of tree work specifications to be drawn up by the applicants appointed arborist/arboriculturist. 3. This assessment/report must be in line with industry best practices and specify works that represent a proportional and well evidenced response to the condition of the trees and the assessed risk they pose, while considering their amenity value and long-term contribution to the local landscape. 4. These proposals, including any replanting measures, once finalised to the satisfaction of the applicant (SC CIC) and their appointed arboriculturist/arborist, should be submitted to Cornwall Council planning service, care of the Case Officer. 5. In the interest of timeliness, I would recommend these proposals be accepted by the LPA as an amendment to the original specification that was submitted in support of PA22/00364; this case remains undetermined. 6. A “fast-track” consultation with the Parish Council and Forestry Officer should be undertaken (if possible and in compliance with planning legislation) 7. Any approval/refusal, including conditions applied to any consented works should be issued promptly once a determination has been made. 8. Subject to the reasonable collaboration of all parties, I would expect the above process to facilitate as swift a conclusion to the matter as possible enabling consented works to be commissioned and undertaken without unreasonable delay. Any agreed actionable matters should be assigned to the appropriate party and a recommended timeline recorded. A collaborative and successful meeting took place as planned and the agreed actions are set out below, along with an updated timetable in red. 1. Following confirmation of the TPO area, an exception notice is only required for the felling of the Ash tree T807. SCCIC to progress this without further delay. An exception notice was submitted on Monday 8th August reference PA22/01398/PREAPP. Given that all parties present accepted that this tree is dead, a positive decision on this application will be issued today which will enable the felling to proceed. 2. TreeWise to submit final specification in line with the requirements of their client (Sailors Creek CIC) and, where acceptable, in line with the advice and guidance provided by CC Forestry Officer. Treewise to confirm timeframe for this. An updated specification was received from Treewise on Monday 8th August. 3. timely fashion. 4. Upon receipt of final specification, Cornwall Council to expedite internal consultation process without to confirm timeframe for delay, with consent to be issued upon completion of this process. and to the Tree Officer on Tuesday 9th August this. Consultation requests have been sent to 2022. Assuming both parties will respond positively and swiftly, a decision on the application should be made well before the end of this month. have scheduled a meeting to specifically provide their consultation on this application in a to confirm date. We are currently awaiting a confirmed date from I trust that this demonstrates that the Council has taken positive steps to progress this matter whilst complying with our duty to ensure that works to trees covered by a Tree Preservation Order are justified to the necessary standards. Please do not hesitate to contact me if you require any further information. Kind Regards, Service Director for Planning & Housing (Chief Planning Officer) | Cornwall Council louise.wood@cornwall.gov.uk | Tel: 01872 322222 TR1 1XU CAUTION: This is an EXTERNAL email which was sent from outside of Cornwall Council's network. Do not click links, open attachments, or reply unless you recognise the sender and know the content is safe. Do not provide any login or password details if requested. Dear Chief Planning Officer, Cornwall Council Re: Paul John Welch, deceased - DOB: 24/04/1967 Our case reference: 3949493 Please find attached a letter from Mr Andrew Cox and Regulation 28 report for your attention. Kind regards,
Sailors Creek CIC REGENERATION Mr Andrew J. Cox H.M. Coroner for Cornwall & the Isles of Scilly H.M. Coroner’s Office, Pydar House, Pydar Street, Truro, Cornwall TR1 1XU 09 August 2022 Dear Mr Cox, Following the Regulation 28 Report issued 15 June 2022, and received 29 June 2022 please find our response below: Actions taken: 05 July 2022 - Letters hand delivered and attached to the boats of 05 July 2022 - Laminated safety notices posted around Sailors Creek and digitally on Sailors Creek CIC website. Emailed to all tenants and members. 31 July 2022 - Majority of mooring ropes removed from trees to the new mooring chain established along the shoreline. 01 August 2022 - Site meeting on the beach at Sailors Creek attended by all concerned parties: - - - - - - - - - (Trefusis Estate) (Trefusis Estate) (Cornwall Council Planning) (Cornwall Council Forestry) (Mylor Parish Council) (TreeWise Cornwall) (Sailors Creek CIC) (Sailors Creek CIC) (Sailors Creek CIC) This meeting was extremely positive: productive and consensus driven. 02 August 2022 - Sailors Creek CIC risk assessment and safety brief adapted for staff and volunteers. ℅ Brain of Brian, Jubilee Wharf, Commercial Road, Penryn, Cornwall TR10 8FG www.sailorscreekcic.org Sailors Creek CIC is a registered Community Interest Company #10959484 Sailors Creek CIC REGENERATION Following site meeting Sailors Creek CIC actions from (Forestry Officer) circulated notes: 1. Following confirmation of the TPO area, an exception notice is only required for the felling of the Ash tree T807. SCCIC to progress this without further delay. Submitted by Sailors Creek CIC 08/08/22 and granted 09/08/22. The dead elms outside TPO to be safely removed, all before the end of September 2022. 2. TreeWise to submit final specification in line with the requirements of their client (Sailors Creek CIC) and, where acceptable, in line with the advice and guidance provided by CC Forestry Officer. Treewise to confirm the time frame for this. Updated 08/08/22, SCCIC seeking advice from erosion engineers unless engineers recommend removal. All tree works will be conducted this winter. : T800, arborists recommend pollarding of undercut Oak tree 3. Mylor Parish Council have scheduled an extraordinary meeting to specifically provide their consultation on this application in a timely fashion. to confirm the date. 4. Upon receipt of final specification, Cornwall Council to expedite internal consultation process without delay, with consent to be issued upon completion of this process. confirm the timeframe for this. and application asap in a positive manner” writes: “as soon as I’ve received receipt of the final specifications is in agreement with the proposed tree works, I shall proceed with the determination of the to Further actions: 5. It was agreed that Sailors Creek CIC should find a method of positioning moored boats further into the creek away from the area overhung by trees. A temporary system using the mussel frames has been implemented as of 08/08/22. A long term mooring access solution is being developed for implementation in 2023. 6. Proposed redirection of footpath and subsequent new planting welcomed by all. Species recommended included Sessile Oak, with an understory of Hawthorn, Blackthorn and Hazel. Sailors Creek CIC contacted Public Rights of Way (Cormac) 09/08/22 re: ongoing concerns that footpath remains open. 7. It was agreed that replanting and planning for a second line of trees further inland is an excellent next step with regard to managed retreat/ increased biodiversity/ stabilisation of the bank. Planting to begin Winter 2022/23. 8. It was agreed that Sailors Creek would develop a tree management plan including professional tree surveys and periodic inspection by Sailors Creek CIC. This tree management plan will be available online at sailorscreekcic.org by the end of September 2022. ℅ Brain of Brian, Jubilee Wharf, Commercial Road, Penryn, Cornwall TR10 8FG www.sailorscreekcic.org Sailors Creek CIC is a registered Community Interest Company #10959484 Sailors Creek CIC REGENERATION 9. It was agreed the mooring chain system provides a welcome alternative to tying to the shoreline trees. Sailors Creek CIC to complete the mooring chain along the length of the beach. Remaining mooring ropes to be removed from trees to the mooring chain along the shoreline once it is complete by the end of 2022. Yours sincerely, ℅ Brain of Brian, Jubilee Wharf, Commercial Road, Penryn, Cornwall TR10 8FG www.sailorscreekcic.org Sailors Creek CIC is a registered Community Interest Company #10959484
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