Kyron Hibbert

18 April 2023 

HM Senior Coroner for Bedford and Luton 
The Court House 
Woburn Street 
Ampthill 
Bedford 

Sent by email only 

Dear Madam 

Kyron Hibbert Deceased 

As you will be aware from our previous correspondence we act on behalf of Forest of Marston Vale 
Trust (the “Trust”)  to whom you issued a Regulation 28 report dated 27th February 2023 following the 
inquest into the death of Kyron Hibbert held on 26th January 20223 . Please treat this letter as our 
client’s response to your Regulation 28 report. This response has been reviewed and approved by the 
Directors of the Trust. 

Our client’s responses to the “Matters of Concern” raised by H M Senior Coroner are set out below. 
For ease of reference H M Senior Coroner’s comments are italicised and emboldened. 

“At the Inquest hearing, The Forest of Marston Vale Trust (‘the Trust’) stated that since 
Kyron’s death they had taken no further action to address the risks of children drowning at 
Stewartby Lakes.” 

At the inquest the Head Ranger of the Trust was asked whether any changes had been made as a 
consequence of this accident. She confirmed they had not .In our written submissions to HM Senior 
Coroner dated 7th  February 2023 we confirmed ; 

“The Trust had a duty under Regulation 3 of the Management of Health and Safety 

Regulations 1999 to review its risk assessment and safety arrangements in the light of Kyron’s 

death. The Trust carried out this review and its conclusion was that the risk assessment in 

place at the time of the incident met the legal duty under Regulation 3 in that it was both 

suitable and sufficient. Having reviewed matters the Trust decided to continue with the roll out 

of the new safety boards around the lake after Kyron’s death. “ 

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 It follows that the action taken by the Trust after the incident was  in accordance with its obligations 
under the prevailing health and safety legislation. 

”However, it was clear from the evidence provided that: 
(1) The specific location where the incident occurred was well known to local children; the 
Head Ranger also admitted that this location, known as 'Location 5' along with 'Location 7' 
was known as an area where people would/could enter the water (albeit that there were signs at 
both locations indicating that swimming was prohibited). Furthermore, 
during the recent heatwave, (albeit this was not known to the Trust) local children had 
been regularly going to Location 5 and using a rope swing they knew to be located there 
). 
(

The Head Ranger confirmed in evidence , which was in line with the content of documentary evidence 
supplied to H M Senior Coroner prior to the inquest, that the Trust was aware of certain locations 
where on occasions members of the public had been seen to enter the lake. The documentation 
supplied to H M Senior Coroner prior to the inquest confirmed the extensive efforts that had been 
made to dissuade people from doing this by reference to physical barriers, warnings/information and 
the provision of safety equipment . Safety measures taken on site were supplemented by messages to 
the local community on social media. 

(2) On Friday 29 July 2022, children had been present at the location using the rope swing 
since at least 2pm and yet their presence and/or the presence of the rope was not 
discovered (
Stewartby Lake this is only incidental to their other duties on any given day and checks are 
not increased around the lake during hot weather (Head Ranger's evidence); 

 - whilst Rangers do check all areas of the park, including 

The Trust’s efforts have always been focussed on preventing people from entering the lake. Suitable 
warnings are in place at all public entrances to the park and at various points around the lakeside 
perimeter path. It is highly significant that all of the children confirmed they were aware they should not 
swim in the lake. Kyron, very sadly, had been given a specific warning from his mother that he could 
well drown if he entered the water. 

The sheer size ,topography and restricted sight lines render routine visual checks impracticable and 
ineffective. 

(3) At the location where the incident occurred, there are varying depths of water but 
(other than the general 'No Swimming' Safety Boards) there was no indication of these 
relative depths provided to visitors. Investigating police observed that there is a ledge of 
the lake that was waist height on the children (this was seen the video footage taken by the 
the children on the day of the incident) and that this shallow ledge drops away suddenly 
into deep water which is believed to be 13 metres deep. It was believed that Kyron had 
fallen beyond the edge of the shallow area. 

The Trust has not seen the video footage referred to but is aware of this issue at very many points 
around the lake . This is one of several reasons why entering the water is forbidden . The risk of 
“Hidden Hazards” is specifically identified on safety signage around the lake. As indicated in our 
written submission the Trust’s view is that placing signs in the very many deep water areas will create 
the impression that those areas that not signed are somehow safe for swimming. 

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 It is important to note in this respect  that the Internal Drainage Board is the public body responsible 
for surface water management in the entire Marston Vale and specifically responsible for the 
management of water levels in Stewartby Lake in its use as a strategic stormwater balancing facility. 
This function entails that there can be a 0.75m variation in depth throughout the year. This depth 
variation translates into a significant encroachment into shoreline. 

(4) At the time of the incident, safety/life-saving equipment at the location of the incident 
was limited to a Safety Board consisting of a throwline in a locked box which required a 
code from Emergency Services (necessitating a 999 call) to release it. The Head Ranger 
explained that the previous life safety rings (costing approx. £40.00 each) had not been 
replaced once the locked throw lines had been installed. The locked throw line was not 
accessible to the children; although, they had seen the Safety Board as they had 
approached Location 5 and noted that there was some kind of float inside it, when they had 
gone to access it when Kyron went into the water they couldn't get the code as their phone 
battery had died. They reported that the box (Safety Board) "felt very far away from where 
we were down at the water" (
have indicated that in addition to the locked throw lines on the Safety Boards, traditional 
safety lines are also to be installed again at Locations 5 and 7; I am concerned that these 
are to be placed next to the Safety Boards rather than closer to the lakeside. Whilst prompt 
access to further life-saving equipment may not have altered the outcome in this incident, 
it might in future incidents. 

). Although since the Inquest, the Trust 

The Head Ranger’s evidence at inquest was that locked throw lines in a number of locations had 
replaced unlocked throw lines, not life rings. There were therefore a combination of locked and 
unlocked throw lines around the lake at the time of this incident. The design of the locked throw lines 
was arrived at following consultation with Bedfordshire Fire and Rescue and reflects that used by the 
local authority in the Bedford area. The locked line was accessible to the children if one of them had 
followed the instructions on the signage to obtain the access code from the emergency operator. The 
written  evidence on the issue was that one of the children had no battery power in her phone. It is 
highly likely others had mobile phones that were working.  It seems reasonable to infer from the 
evidence that the fact that  Kyron , a non-swimmer, immediately went under the water and did not 
resurface meant the children were not seeking rescue equipment. 

The Trust has looked at  installing additional unlocked throw lines in areas where there are secure 
lines in place. It has also considered whether these can be located closer to the edge of the lake .The 
locked lines are on the main lakeside walkway where they are most visible to members of the public. 
As has been highlighted in evidence and  previous written submissions, the water level of the lake 
varies significantly throughout the year as the lake  is part of the flood defences in the area. We have 
described the role of the IDB in response to point 3 above. To illustrate the impact of this on the 
shoreline we attach two photographs taken in March 2023 showing the general area where this 
incident occurred . It can be seen that the area where the children were playing is completely under 
water. 

Whilst it is not accepted the secure throw lines were “very far away” from the water , in order to deal 
with HM Senior Coroner’s concern on this issue the Trust will install additional unlocked lines closer to 
the high water mark of the lake at locations 5 and 7 , and at the other points around the lake and 
closer to the edge of the lake in locations where there have been previous incidents of swimming. 

These new throw lines with accompanying safety signage will be in place by 1st June 2023. 

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 All at the Trust was devastated by Kyron’s death and it will go above and beyond its legal duty to try 
and avoid a similar incident. That said the Trust believes the evidence in this case sadly confirmed the 
positioning or availability of life saving equipment would not have altered the fatal outcome of this 
case. 

As well as installing the new throw lines and signage referred to above , the Trust has resolved  to 
issue messages to local schools in periods of warm weather warning of the dangers of accessing the 
lake, and encouraging them to share this information with their pupils. This will supplement information 
already provided by the Trust via social media. 

Yours faithfully 

Partner 
DAC Beachcroft 

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 Gullwatch - Other 

 Gullwatch 2- from top of bank down to edge. - Other