Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0416, written 28 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Dec 2022 |
|---|---|
| Reference | 2022-0416 |
| Deceased | Emma Powell |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Other related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. His Majesty’s Government c/o Prime Minister’s Office, 10 Downing Street, London SW1A 2AA 2. Tesco PLC, Tesco House, Shire Park, Kestrel Way, Welwyn Garden City, Hertfordshire AL7 1GA 1 CORONER I am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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 the 16th Of July 2022 I commenced an investigation into the death of Emma Louise Powell (DOB 22.10.97 DOD 15.7.2). The investigation concluded at the end of the inquest on the 8th of December 2022. The conclusion of the inquest was that the death was the result of an accident, the cause of Miss Powell’s death being recorded as 1(a) Immersion 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows : On the 14th of July 2022 at Conwy Morfa, the deceased got into difficulties whilst paddleboarding. The current of the Spring tide resulted in her being unable to make her way to safety and she was recovered from the water after being submerged for a period in excess of ten minutes. She was taken to Ysbyty Gwynedd where her death was confirmed shortly after midnight on the 15th of July. 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. The MATTERS OF CONCERN are as follows. – The evidence at inquest indicated that Miss Powell had purchased a paddleboard from Tesco at Llandudno Junction on the evening of the 14th of July 2022, that she had taken it to Conwy Morfa and had thereafter used it in an unsafe manner, whereby she did not wear any life saving equipment and the safety leash on the board was by way of an ankle leash which was inappropriate for the fast flowing water. The evidence further indicated that at the point of sale, there was no safety advice or guidance provided in relation to either the advisory wearing of a safety vest, or the need to be aware that the positioning of a safety leash should take into account the environment/water conditions where the paddleboard is to be used as per the below information: Unless action is taken to improve the provision of information to purchasers of paddleboards and/or to regulate the sale of paddleboards to ensure that the provision of advice of this nature becomes a mandatory requirement at the point of retail sale, then there is an ongoing risk that further accidents will occur and that lives may be lost as a result. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 22nd of February 2023 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 Family of the Deceased and to the Chief Coroner. 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 Dated 28th December 2022 Signature Senior Coroner for North Wales (East and Central)
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.
Kevin Hollinrake MP
Parliamentary Under Secretary of State
Department for Business and Trade
Old Admiralty Building
Admiralty Place
Whitehall
London
SW1A 2DY
Mr John Gittens
Senior Coroner North Wales (East and Central)
County Hall
Wynnstay Road
Ruthin
LL15 1YN
24 March 2023
Dear Mr Gittins,
INQUEST INTO THE DEATH OF EMMA LOUISE POWELL
Thank you for your Regulation 28 Report (Prevent Future Deaths), dated 28 December
2022, following your investigation and inquest into the death of Emma Powell, caused by
submersion in water while using a recently purchased paddleboard.
The Report was sent to the Prime Minister’s Office at No10 Downing Street and was
subsequently redirected to me to respond as the Minister responsible within the Department
for Business and Trade. I apologise for the delay in responding.
I would first like to say how deeply saddened I was on hearing of this tragic death. If you
have an opportunity, please pass on my condolences to Miss Powell’s family.
I would like to assure you that the Government is committed to ensuring that the UK has a
product safety system designed to provide a high level of protection. This applies to the
purchase of any consumer product, including paddleboards such as the type involved in this
tragic incident. The findings of your inquest provide an opportunity to assess whether further
lessons can be learned.
The regulations that apply to paddleboards are dependent upon a number of factors,
including the length of the paddleboard and its intended use. The two sets of regulations
that could apply are the General Product Safety Regulation 2005 (GPSR), and the
Recreational Craft Regulations 2017 (RCR).
Manufacturers of products such as paddleboards are under an obligation to place only safe
products on the market (Regulation 5 of GPSR). They must also provide safety information
to enable consumers to assess risks that are not immediately obvious without adequate
warnings and to take precautions against those risks (Regulation 7 of GPSR). Distributors
have a duty of care to ensure that products they offer for sale comply with the law; are safe;
and to pass on information on the risk posed by the product (Regulation 8 of GPSR).
Similarly, under the RCR manufacturers are required to ensure products do not endanger
the health and safety of persons when used as intended (Regulation 6 of RCR). As with the
GPSR, distributors have a duty of care to ensure the product complies with the law;
specifically that it is safe (Regulation 27 of RCR); and is accompanied by any instructions
provided by the manufacturer on their safe use (Regulation 28 of RCR).
Under both sets of regulations, when sold, a product should therefore include information
on ‘how’ it is to be used safely as you suggest. We know that, separately to this incident,
some manufacturers are printing safety information on the paddleboard to help ensure the
information is always readily available when using the product. This is a welcome step by
manufacturers.
Your Report states that there was no evidence that there was advice or instruction given at
the point of sale on the safe use of the product. As stated above there are obligations and
duties on both manufacturers and distributors to ensure adequate advice is provided. I have
therefore referred your Report to Hertfordshire Trading Standards, the Primary Authority
responsible for the regulatory relationship with Tesco, so that they may decide if any further
action is needed in addition to that already taken in this specific case.
I have also asked the Office for Product Safety and Standards (OPSS) to write to the
Business Reference Panel, that includes the British Retail Consortium and a number of
major retailers, such as Tesco, to ensure that distributors are aware of this issue and their
obligations.
In addition, I have asked OPSS to liaise with their enforcement partners, and through them
where appropriate manufacturers, to ensure that there is awareness of this incident so that
if necessary appropriate action can be taken.
Finally, OPSS will also write to the British Standards Institute so that they may consider
whether the industry standards relating to paddleboards remain appropriate.
I am copying this response to Tesco PLC, Hertfordshire County Council Trading Standards,
and the Prime Minister’s Office at No10.
Thank you again for bring this issue to my attention.
Yours sincerely,
KEVIN HOLLINRAKE MP
Parliamentary Under Secretary of State – Department for Business and Trade
Tesco Stores Ltd Tesco House Checkout Kestrel Way Welwyn Garden City AL7 1GA 21 February 2023 John A. Gittins H.M. Coroner H.M. Coroners Office County Hall Wynnstay Road Ruthin LL15 IYN Dear Mr Gittins Re. Report for the Prevention of Future Deaths Inquest of Emma Louise Powell I am writing on behalf of Tesco Stores Limited (Tesco') in response to your letter dated 28 December 2022 in relation to this matter. First of all, please can I express on behalf of Tesco our sadness at the death of Miss Powell. Tesco work hard to ensure we only sell products that are safe whether that be our own-brand or branded lines and to learn that any of our customers have died whilst using one of our products is very upsetting. Tesco sell two paddleboard products which are branded from a single supplier and are not Tesco lines. We only sell these in a limited number of our large Extra and Superstores that are at waterside' locations. Following your letter (and in fact before we received it, based on the media reports on your Hearing) we have been including safety warnings, accompanying working with our supplier to review the products and information, them. Based on this review, we have concluded that the products are safe and have appropriate instructions. However we have agreed with the supplier that a sticker will be added to the front of the product packaging with the following information: Tesco Stores Ltd, (519500). Company Registered in England. Registered Office: Tesco House, Kestrei Way, Weiwyn Garden City, Hertfordshire, ALl 1GA 1 ¯ IMPORTANT PLEASE READ BEFORE USE: Life saving devices such as Life Jackets OR Buoyancy aids should be used at all times and checked before each use. ¯ Contains calf leash. IMPORTANT: not to be used in fast flowing water or where there's a risk of snagging/entrapment. Please note this sticker is currently being designed (we have had to seek the permission of British Canoeing and obtain a high resolution image, both of which we now have), but it will be approximately A5 in size. The sticker will be included on all product units which will be delivered to stores for sale in Spring / Summer 2023. We also have a limited number of units (c. 600) which were delivered to stores in 2022 so do not display the new sticker. Small numbers of these units are currently sold on an ad hoc basis and arrangements have been made for stores to receive and affix the stickers to these units, once the stickers are available. We anticipate stickers being ready for distribution to stores by April 2023. Working with British Canoeing, they have updated the graphic to include a QR code that takes the user to wider safety information on their website. We believe that placing this sticker on the front of each product box is the best way to inform customers of the steps they can take to manage the risk of snap / entrapment, by positioning and/or using a leash appropriate to the environment they paddle in. By securing the sticker on the box, the information is made available to both the customer who purchases the product in-store, and to other users who may not have been in-store but otherwise receive the product after the point of sale. We have also agreed to share information about what we have done and the support we have received from British Canoeing with other retailers via the British Retail Consortium's Product Safety Committee. Regards Technical Director, Home & Clothing For and on behalf of Tesco Stores Limited Tesco Stores Ltd, (519500). Company Registered in England. Registered Office: Tesco House, Kestrel Way, Weiwyn Garden City, Hertfordshire, AL7 1GA 2
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