Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

Date of report	24 Jul 2017
Reference	2023-0105
Deceased	Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi
Coroner	Alan Craze
Coroner area	East Sussex
Category	Other related deaths
Source	judiciary.uk record · original PDF
Responses published	5

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. The Secretary of State for Transport
2. The Health and Safety Executive
3. The Chairman of the National Water Safety Forum
4. The Operations Director RNLI
5.
6.
7.
Birnberg Peirce Solicitors
8. Royal Society for the Prevention of Accidents
9. Local Government Association
10. The Chairman, Rother District Council
11. Maritime and Coastguard Agency
12. East Sussex Divisional Commander, Sussex Police

CORONER

I am ALAN RO MILLY CRAZE, Senior Coroner, for the coroner area of East Sussex.

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.

INVESTIGATION and INQUEST

On 29
On 25th

of July 2016 I opened an investigation into the death of MOHIT

of August 2016 I opened investigations into the deaths of INTHUSHAN

of July 2016 I commenced an investigation into the death of GUSTAVO SILVA

On 24th
DA CRUZ.
DUPAR.
SRISKANTHARASA, GURUSHANTH SRITHAVARAJAH, KENUGEN
SATHTHIYANATHAN, KOBIKANTHAN SATHTHIYANATHAN and NITHARSAN RAVI.
The investigations concluded at the inquest into all seven deaths on 30th June 2017. The
conclusions of the inquests are summarised on the seven Record of Inquest forms,
copies of each I have attached to this letter.

CIRCUMSTANCES OF THE DEATH

of June 2016 Mr. Da Cruz and Mr. Dupar went into the sea at Camber Sands,

On 24th
Rye. Mr. Da Cruz was seen to be in difficulties and his body was later washed up on the
shore. Mr. Dupar was seen to be in difficulties and was brought to the beach
unconscious. He had suffered from hypoxic brain damage and died at Ashford Hospital,
Kent on the 28th of July. The other five deceased were all part of a party of five youn~
Sri Lankan men who travelled together to Camber to enjoy a day at the beach on 24t of
August 2016. They all went into the sea at a time when the tide had started to come in.
It is not known how well any of them could swim. It is thought that they were all on a
sand bar when they were overtaken and cut off by the incoming tide. All five bodies
were recovered to the shore that day, or found after the tide had receded. The RNLI
had recommended deploying lifeguards at the beach in 2013 but Rother District Council
had not implemented that recommendation. It was accepted quite quickly after these
deaths and lifeguards are now deployed. There was considerable evidence at the
inquest on the question of whether that step, and others recommended, would have
prevented any of the deaths. It should be noted that the length of the beach from which
people can swim is about three miles and the distance between high water mark and low
water mark is as much as a kilometre in some tides.

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:-

(a) There are possibly lessons in the circumstances of and the issues surrounding these
deaths which may be of help to others on a national basis.

(b) There appears to be no formal governance or control of risk management
requirements. Should the present, virtually voluntarily, structure be examined? Could
perhaps the Marine and Coastguard Agency, who have enforcement powers akin to
those of the Police, be given more resources and take a bigger role than they currently
have? The problem is an increasing one. The evidence suggested that on a pleasant
hot summer's day 25,000 to 30,000 people visit Camber Sands, many of whom have
language difficulties and do not speak much English, and many others of whom have no
experience of going into the sea. The question is whether leaving matters to a charity is
really the best basis of a structure intended to spearhead a possibly overdue attempt to
modernise, harmonise, and improve the safety regime, given so many changes at
Camber.

(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which
everybody at these inquests agreed to be crucial to the necessary educative
process,
(iv) improvement, considered vital, of education and awareness of coastal
dangers amongst children and those who live far from the sea.

(d) Inevitably resource and monetary considerations affect decision making by those
charged with safeguarding people like the seven who died here. Perhaps that is another
reason why a review of the current system may well be needed.

(e) There was pessimism expressed at the inquests that any measures could prevent
most deaths, only reduce them. In those circumstances, should there be consideration
by central government of taking powers to restrict public use, according to daily
circumstances, of parts or all of certain beaches? Certainly a localised study, on a
national model, should be carried out. I believe it has elsewhere in the world.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by the 18 September 2017. I, the Coroner, may extend this 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.

I
I
iIi

I
I

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and all those persons or
organisations names at the head of ii.

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.

Two expert witnesses gave evidence at the inquests and one of them,
Middlesex University, offered a paper raising 12 issues which I have attached to my
Regulation 28 Report because it may assist discussion (Appendix A).

10 Dated 24th July 2017 //c ..
,J\i.. ..lL:.. .<: .....••.j

.·V\. J 1.. /

•

<
Signed.....
Alan R. Craze
H.M. Senior Coroner
East Sussex

Record of Inquest

Following an investigation commenced on the 24th day of July 2016
And Inquest opened on the 2nd day of August 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZ;E Senior
Cormier in the coroner's area for East Sussex, the following findings and determinations were made:
I. Name of Deceased (if known)

Gustavo SILVA DA CRUZ

2. Medical cause of death

Drowning

Asthma

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

On 24th July 2016 the deceased, who was an asthma sufferer, went into the sea at Camber Sands to bathe. He was
seen to get into difficulties and his body was later washed up on the shore. He was deceased and rigor mortis had set
in. The RNLI had recommended, amongst other measures, deploying life guards at the beach in 2013 but this had not
happened. Of course it is not known whether such a step would have prevented his death, but ii has since been
implemented.

4. Conclusion of the Coroner as to the death

Misadventure

5. Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death

Record of Inquest

Following an investigation commenced on the 29th day of July 2016
And Inquest opened on the 9th day of August 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZE Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

1. Name of Deceased (if known)

Mohit DUPAR

2. Medical cause of death

Hypoxic brain injury

Out of hospital cardiac arrest

Drowning

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

On 24th July 2016 the deceased was seen to be in difficulties in the sea at Camber Sands, Rye. He was brought to the
beach unconscious. He was taken to Ashford Hospital suffereing from hypoxic brain damage and died there on 28th
July 2016. The RNLI had recommended, amongst other measures, deploying lifeguards at the beach in 2013 but this
had not happened. Of course it is not known whether such a step would have prevented his death, but it has since
been implemented.

4. Conclusion of the Coroner as to the death

Misadventure

5. Futther particulars required by the Births and Death Registration Act 1953 to be registered concerning the death

I
I
I

Record of Inquest

Following an investigation commenced on the 25th day of August 2016
And Inquest ope11ed on the 6th day of September 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZE Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

I. Name of Deceased (if known)

lnthushan SRISKANTHARASA

2. Medical cause of death

Immersion (drowning)

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

The deceased one of a party of 5 young Sri Lankan men who travelled to Camber to enjoy a day at the beach on 24th
August 2016. They all went into the sea, at a time when the tide had started to come in. It is thought they were all on a
sandbar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore
deceased or found after the tide receeded. The RNLI had recommended deploying life guards at the beach in 2013 but
this had not happened. Of course it is not known whether such a step would have prevented his death, but it has
since been implemented.

4. Conclusion of the Coroner as to the death

Misadventure

5. Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death

Record of Inquest

"c 0

Following an investigation commenced on the 25th day of August 2016
And Inquest opened on the 6th day of September 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZE Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

1. Name of Deceased (if known)

Gurushanth SRITHAVARAJAH

2. Medical cause of death

Immersion (drowning)

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

The deceased was one of a party of 5 young Sri Lankan men who travelled to Camber to enjoy a day a~ the beach on
24th August 2016. They all went into the sea, at a time when the tide had started to come in. It is though they were all
on a sandbar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore
deceased or found after the tide receeded. The RNLI had recommended deploying life guards at the beach in 2013 but
this had not happened. Of course it is not known whether such a step would have prevented his death, but it has
since been implemented.

4. Conclusion of the Coroner as to the death

Misadventure

5. Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death

Record of Inquest

Following an investigation commenced on the 24th day of August 2016
And Inquest opened on the 6th day of September 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZ~ Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

1. Name of Deceased (if known)

Kenugen SATHTHIYANATHAN

2. Medical cause of death

Immersion (drowning)

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

The deceased was one of a party of 5 young Sri Lankan men who travelled to Camber to enjoy a day at the the beach
on 24th August 2016. They all went into the sea, at a time when the tide had started to come in. It is th1mght they were
all on a sandbar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the
shore deceased or found after the tide receeded. The RNLI had recommended deploying life guards at the beach in
2013 but this had not happened. Of course it is not known whether such a step would have prevented his death, but it
has since been implemented.

4. Conclusion of the Coroner as to the death

Misadventure

Record of Inquest

Following an investigation commenced on the 24th day of August 2016
And Inquest ope11ed on the 6th day of September 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZ;E Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

I. Name of Deceased (if known)

Kobikanthan SATHTHIYANATHAN

2. Medical cause of death

Immersion (drowning)

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

The deceased was one of a party of 5 young Sri Lankan men who travelled to Camber to enjoy a day at the beach on
24th August 2016. They all went into the sea, at a time when the tide had started to come in. II is thought they were all
on a sandbar when they were overtaken and cut off by the incoming tide. All five bodies were recover~d to the shore
deceased or found after the tide receeded. The RNLI had recommended deploying life guards at the beach in 2013 but
this had not happened. Of course ii is not known whether such a step would have prevented his death; but it has
since been implemented.

4. Conclusion of the Coroner as to the death

Misdaventure

5. Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death

Record of Inquest

Following an investigation commenced on the 24th day of August 2016
And Inquest opened on the 6th day of September 2016;
At an inquest hearing at Muriel Matters House on the 26th day of June 2017 heard before ALAN ROMILLY CRAZE Senior
Coroner in the coroner's area for East Sussex, the following findings and determinations were made:

I. Name of Deceased (if known)

Nitharsan RAVI

2. Medical cause of death

Immersion (drowning)

3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the
deceased came by his or her death

The deceased was one of a party of 5 young Sri Lankan men who travelled to Camber to enjoy a day at the beach on
24th August 2016. They all went into the sea, at a time when the tide had started to come in. It is thought they were all
on a sandbar when they were overtaken and cut off by the incoming tide. All five bodies were recover~d to the shore
deceased or found after the tide receeded. The RNLI had recommended deploying life guards at the b~ach in 2013 but
this had not happened. Of course it is not known whether such a step would have prevented his death, but it has
since been implemented.

4. Conclusion of the Coroner as to the death

Misadventure

5. Fmther particulars required by the Bi1ths and Death Registration Act 1953 to be registered concerning the death

Appendix A
Issues raised by Professor Ball

I0.

11.

Events at Camber Sands in 2016 have raised questions about beach safety at Camber Sands
and more generally.

The risk of drowning at Camber Sands and on other UK beaches is low.

The risk of drowning on UK beaches is not increasing. At Camber Sands there is insufficient
evidence to identify any trend.

Existing beach patrol services at Camber Sands have been supplemented with an RNLI
lifeguard service, initially for 3 years, as a precautionary measure.

Firm evidence of the effectiveness of lifeguarding services is, however, lacking. Given the
likely interest in lifeguard services post 2016, this needs to be corrected so that coastal
authorities can make evidence based and proportionate decisions about the need for
lifeguards.

The first and overwhelmingly important line of defence against drowning lies in the
competencies and risk awareness of beach users.

Competency here relates mainly to an ability to swim in calm and open water. More
emphasis should be placed upon training children and young people in this regard.

At Camber Sands various measures increase awareness of the beach hazards at that location.

On a national basis there is a tendency to describe beaches (and other public places) as safe.
It may be time to shift to a more frank approach which provides information on the specific
hazards peculiar to each location ( e.g. at Camber Sands on sand banks).

There is some evidence from abroad that ethnicity is a significant risk factor for drowning.
Given the ethnic mix of British society this should be investigated.

The Camber Sands Inquest has brought to light significantly different approaches to the
assessment of risk and subsequent risk management choices. These have ethical and resource
implications which have the potential to impact on the overall health, safety and welfare of
society. The government's recent investigation of Health and Safety concluded that safety
interventions should be risk based and proportionate, and evidence based. This should
continue.

12.

There is a tendency to entrust risk assessment to third parties. However, this task is not
delegable and is best perfonned by those with intimate knowledge of the location.

Responses

5 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.

Response from Department for Transport (PDF)

) 

I 

From the Secretary of State 
The Rt. Hon. Chris Grayling 

Great Minster House 
33 Horseferry Road 
London 
SW1P4DR 

Web site: www.gov.uk/dft 

• 

Department 
for Transport 

Alan R Haze 
Her Majesty's Senior Coroner for East Sussex 
31  Station Road 
Bexhill-on-Sea 
East Sussex 
TN401RG 

Thank you for your letters of 24 July to me and the Maritime and Coastguard 
Agency, enclosing your Regulation 28 report to prevent further deaths. I am 
replying on behalf of the Maritime and Coastguard Agency, and Executive 
Agency of this Department, following discussions with them. 

Following the inquest held on 30 June 2017 and your investigations into the 
deaths of seven men at Camber Sands in the summer of 2016, you 
recommended that action should be taken to prevent the risk of future deaths 
of this nature and raised a number of matters of concern.  I agree that lessons 
can be learned from this tragic incident and in this response,  I set out some 
background and address each of your key points in turn. 

Background 

The MCA has a number of UK-wide functions,  including search and rescue 
(SAR) and the surveying and inspection of ships. The MCA is a member of 
the National Water Safety Forum (NWSF) - which promotes accident 
prevention through education - and voluntarily contributes financially to the 
NWSF's running costs.  In February 2016, the Minister of State for Transport 
at that time, 
Prevention Strategy; a copy is enclosed. This Strategy promotes a 
collaborative approach to accident prevention for stakeholders with an 
interest in water safety,  both inland and on the coast.  Turning to the key 
points raised in your letter, l would offer the following responses. 

, launched the NWSF's National Drowning 

 
 
 
 No formal governance or control of risk management 

There are more than 11,500 miles of coast around the United Kingdom, and 
the Government is opening coastal paths to support public health, fitness and 
wellbeing, whilst encouraging people to enjoy this country's coast and 
beaches.  It is the responsibility of landowners (in many cases the local 
authority) who have a duty of care to assess the safety risks associated with 
their coastlines and beaches and to determine whether they need to put in 
place safety interventions. This may include safety signage and/or, where 
appropriate, professional lifeguarding services provided by the Royal National 
Lifeboat Institution (RNLI), the Royal Life Saving Society (RLSS) and other 
organisations. 

A  current gap in risk management has been identified as a national issue and 
has been recognised through MCA's work with the NWSF.  Target 2 of the 
Strategy states that: 'Every community with water safety risks should have a 
risk assessment and water safety plan in place'.  Presently the risk 
management of water safety risks is conducted on an ad hoc basis and takes 
many different forms. To gain an understanding of the national situation, the 
MCA will fund an  independent review of the current system of risk 
management pertaining to beach safety and the prevention of drowning. This 
will include research into how the UK compares to other leading nations such 
as Australia, New Zealand, Canada, Netherlands and Germany. The review 
will also compare other similar ris~ themes such as road traffic or fire harm, 
for the prevention of injury and will report by end of July 2018. 

MCA has enforcement powers akin to the Police and should be given 
resources to take a bigger role 

As you suggest in your findings, the MCA does have enforcement powers 
akin to the Police, but these only extend to matters contained within the 
Merchant Shipping Act and similar primary legislation and associated 
regulations.  The MCA also has powers as the Receiver of Wreck for 
managing access to beaches to guard against looting and to protect wreck, 
salvage, stranded whales and similar wildlife.  However, the MCA's officials 
have no powers to restrict access to beaches generally nor to prevent 
swimming. 

What is the MCA doing? 

As part of its response to the National Drowning Prevention Strategy, which 
aims to halve the number of accidental drownings by 2026, the MCA has 
developed its own Drowning Prevention Strategy with an implementation 
plan; again, a copy is enclosed. 

 In addition, we will review what resources we need to contribute effectively to 
accident prevention.  Any additional identified resources will be built into the 
Agency's annual Business Plan,  published each April. 

The Agency is already actively involved in some prevention work,  regularly 
advocating safety messages and campaigns at targeted audiences.  For 
example, in response to recent research indicating a growing public appetite 
for online guidance, the MCA launched this summer a Coastal Safety 
mini-website 1 which distils simple safety information in one place, for the 
benefit of families and casual beach visitors. 

Since 2007, the MCA has contributed coastguard incident data and provided 
staff resource to maintain and develop the NWSF Water Incident database 
(WAID) which records in detail, fatal water-related accidents. This data is 
used to analyse national drowning incident trends and to inform each member 
organisation's prevention strategies. The Forum is committed to continuing to 
expand, develop and draw on the database, which provides the evidence 
needed to monitor progress towards the National Drowning Prevention 
Strategy's vision and targets. 

The MCA has recently started working closely with the RNLI  on coastal risk 
management, including a programme of visits to landowners to discuss and 
advise on local risks and the potential for raising public awareness through 
targeted safety interventions. 

In addition,  Her Majesty's Coastguard can call on its 3,500 volunteer 
Coastguard Rescue Officers based in  local communities on the coast to 
provide engaging safety talks and demonstrations, and this is something 
MCA will be looking to do more of. The MCA and I are also keen to extend 
those opportunities to communities in our bigger cities so that people from 
urban backgrounds are better prepared for the risks they may encounter 
when they venture to the seaside. The Agency has recently nominated a 
number of coastguard officers to act as National Drowning Prevention 
Officers to target particular high - risk activities such as diving, motorboating 
and swimming. 

In summary, Her Majesty's Coastguard and the MCA are already engaged in 
work to support accident prevention messages.  Working alongside the other 
organisations in the NWSF, the MCA is also actively exploring the scope for 
committing more of its existing resources to implementing its own and the 
national Drowning Prevention Strategy. 

1 https://coastguardsafety.campaign.gov.uk/ 

 The Agency will also conduct an independent review of its accident 
prevention activity and benchmark what it does against similar maritime 
countries in the world .

Rt Hon Chris Grayling MP 

SECRETARY OF STATE FOR TRANSPORT

Response from National Water Safety Forum (PDF)

national
water safety
forum

National Water Safety Forum
Secrelariot clo
The Royal Society for the Prevention or Accidents
28 Calthrope Road, Edgbaston,
Birmingham 8 15 1RP
YAvw,natlonalwalersafety.org,uk
info@nalionalwatersafely.org
01 212482000

Mr Alan Craze
H.M. Senior Coroner for East Sussex
31 Station Road
Bexhill-on-Sea
East Sussex
T40 1RG

14 September 2017

Dear Mr Craze,

Re:

ARC/MAO/

Kenugen SATHTHIYANATHAN (deceased)
/Nitharsan RAVI (deceased)
/Kobikanthan SATHTHIYANATHAN (deceased)
/lnthushan SRISKANTHARASA (deceased)
/Gurushanth SRITHAVARAJAH (deceased)
/Gustavo SILVA DA CRUZ (deceased)
/Mohit DUPAR (deceased)

Thank you for your letter dated 24 July 2017, under rule 43 concerning the above matter.

The National Water Safety Forum was formed in 2005 in response to a governmental
enquiry into water safety. It is a voluntary organisation funded by its members and a grant
from the Maritime and Coastguard Agency (MCA). Governance is provided through a
coordinating group with the Royal Society for the Prevention of Accidents (RoSPA) fulfilling
the role of secretariat.

The Forum 's aim is to develop, promote and share best practice in water safety and risk
management to reduce accidental death, accidents and water related self-harm. To help
achieve this it established a water accident and incident database, WAID and actively
curates and maintains a variety of data sources populating it. The MCA, RoSPA and the
RNLI support the administration of WAID through the provision of staff time.

Each year a drowning report is published providing the UK's definitive record of drowning
fatalities and causal analysis. This intelligence and further research commissioned by the
Forum informed the development of the UK's first National Drowning Prevention Strategy
published in February 2016 (www.nationalwatersafety.org. uk/strategy). With the support of
UK Government a strategic target was set to reduce drowning in the UK by 50% by 2026.
The Forum does not have any legal, regulatory or enforcement powers vested in it.
In response to your letter of 24 July the NWSF co coordinating group has the following
comments:

Your matters of concern

There are definitely lessons to be learned from this accident and the outcome of your inquest
has proved very valuable indeed concerning that.

National Waler Safety Forum - Working together for water safety

. '

fatal accidents are

Notwithstanding the depth and scope of your inquest investigation as a requirement of the
legal system, the forum is not aware of any other formal or legal requirement for any
organisation to investigate such incidents, in the way that, for instance, a road traffic
to
accident or house fire
investigations the root causes and full range of lessons could be identified even more
effectively. The forum would welcome any improvements that could be to be made into
drowning fatality investigations. This would help ensure all lessons are identified, that can be
taken account of by landowners when deciding what risk control measures should be put in
place to prevent drowning in areas under their jurisdiction. Such a requirement could be of
benefit to you and your colleagues as well as a source of evidence in the conduct of
inquests.

investigated. But with

improvements

Governance and control of risk management

The forum believes that governance and risk management requirements for beach safety
are not satisfactory. There should be an increased onus and clarification for local authorities,
beach owners and operators (generically referred to as 'landowners'), to ensure that they
have in place a beach safety governance framework and current risk assessment for their
area of responsibility and this should be a statutory obligation especially where their beach
facilities are advertised as available to the public. The forum would support a review of the
governance and risk management arrangements for beach safety in order to answer the
question 'who has responsibility for beach safety and how is that responsibility met?' The
answer should set out the legal and duty of care requirements. The forum believes that if
landowners are obliged to comply with governance and risk management requirements then
the likelihood of accidental drownings would decrease. The forum believes that this principle
holds good for all water frontage with public access, be it inland and coastal, not just
beaches.

National Water Safety Forum action taken to prevent future deaths

The publication of the National Drowning Prevention Strategy was a 'call to action' to those
organisations, local authorities and government, that are in a position to make changes in
order to reduce the risk of accidental drowning and water related self-harm. It's 5 targets set
out how this can be achieved.

The forum itself is actively promoting those targets and endeavouring to track and report on
progress. We are due to publish a report covering progress since the strategy was
published.

For ease of reference the targets are set out below with an example comment on each,
further details concerning progress are contained in our soon to be published annual report.

Every child should have the opportunity to learn to swim and receive water safety
education

We support the 'schools swimming review' which has been presented to government. We
would like the recommendations of this review to be accepted.

Every community with water risks should have a community level risk assessment
and water safety plan

Through our network and direct with the Local Government Association we are influencing
communities to carry out community level risk assessments and to have a water safety plan.
There are some excellent of examples of best practice but these are far outweighed by those
who have not given this matter the vital attention it deserves.

National Waler Safely Forum - Worhing together for water safety

To better understand water related self-harm

One of our coordinating group organisations had led on this target and the results will help
the nation's interested organisations better understand water related self- harm to such an
extent that we will soon be in a position to review this target and be more specific with it.

Increase awareness of everyday risks in, on and around the water

The forum's network has helped organisations work more closely together to promote
awareness of the risks associated with water and influence behaviour change among the
general public.

All recreational activity organisations should have a clear strategic risk assessment
and plans that addresses key risks

The leadership of the forum's group, which will spearhead the promotion of this target, is
being reviewed in preparation for action. To date we have spread best practice examples of
recreational governing body organisations that have produced guidance and codes for their
members.

Additionally, the forum is intending to update and expand the use of the WAID database in
order to produce even more compelling evidence that can be used by various organisations
in order to target their resources to prevent drowning. A barrier to progress is finance; the
forum is seeking to identify suitable sources of funding for this WAID development work.

The forum's work is helping to raise awareness of beach safety and through our network,
communication and conference channels we are promoting examples of best practice. Our
real strength and greatest opportunity is to influence others and this is what we are doing.

But in summary we would urge the chief coroner to call for clarification concerning 'who is
responsible for beach safety' and 'how must that responsibility be met'. We believe by
answering this question the landowner will be much clearer about their obligations to
conduct and act on a risk assessment of the shoreline, shallow water and water based
activity that takes place within their jurisdiction. For instance, if the risk assessment identifies
a lifeguard unit as a control measure, they should be obliged to ensure that service is
provided. This will be supported by a robust investigation requirement for when things go
wrong. This change will save lives.

Thank you for writing to the Forum and giving us the opportunity to comment and outline
how our work and the National Drowning Prevention Strategy can contribute to helping to
ensure the risk of these tragic accidental fatalities is reduced.

Chair of the National Water Safety Forum

National Water Safety Forum - Working loge/her for waler safely

Response from Rospa (PDF)

RoSPA
28 Cal thorpe Road
Birmingham . 81 5 ! RP
United Kingdom

T: • 44 (0) 12 1 248 2000

help@rospa.com
www.rospa.com

Patron: Her Majesty The Queen

Mr Alan R Craze
HM Senior Coroner for East Sussex
31 Station Road
Bexhill-on-Sea
East Sussex
TH40 1RG

15th September 2017

Dear Coroner Craze,

Response to Rule 43 letter following the fatal incidents at Camber Sands in
July and August 2016

Thank you for your letter of July 24, 2017. We were greatly saddened by last year's
deaths at Camber Sands, and our thoughts remain with the families and friends of
the young men who died.

We welcome the opportunity to respond to the matters of concern that you set out.

Background

Drowning and other water-related harms in the UK account for, on average, 600
deaths annually. Of these cases , accidental drowning deaths number, on average,
400 per year - approximately one fatal drowning event every 22 hours. This is higher
than the number of accidental fire deaths in the home or cycling deaths on the road ,
yet, historically, drowning prevention has not experienced similar awareness levels or
support.

The Royal Society for the Prevention of Accidents (RoSPA) is a national charity,
currently marking its centenary, with no regulatory or enforcement powers. Our
approach, within the existing structures for water safety, is to seek to influence,
inform, coordinate activity and advise. A considerable amount of our resources are
spent seeking to engage with government departments and local authorities to bring
a coherent and focused approach to tackling the burden of drowning.

The Royal Society for the Prevention of Accidents
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Our efforts, with many of the named organisations in your letter, have focused upon
a voluntarily collaboration within the National Water Safety Forum (NWSF), for which
RoSPA provides the secretariat. Primarily, this has been to track and identify
drowning events, produce information and guidance and recently to produce

The UK national drowning prevention strategy 2016-2026, which was launched in
February 2016 and which we understand was discussed during the Inquest.

Of particular relevance to our response are the following strategy targets:

Every community with risk to have a water safety plan and risk assessment

Every child to have the opportunity to learn swimming and water safety skills

Increase in awareness of the everyday risks associated with water.

These three targets, agreed by members of the NWSF, are intended to address
many of the immediate and underlying factors which we understand may have
contributed to the loss of life at Camber Sands.

The full strategy can be read at www.nationalwatersafety.org.uk/strategy/ and next
month's RoSPA National Water Safety Conference in Bristol will discuss how to take
forward the strategy's delivery.

Matters of concern

We have set out our response as per the points in your letter and here we address
these in turn.

(a) There are possibly lessons to be learnt in the circumstances of and the
issues surrounding these deaths which may be of help to others on a national
basis.

We are of the opinion that wider lessons can be learnt from the fatalities in July and
August 2016 at Camber Sands. Indeed, learning from accidents, near misses and
other incidents - irrespective of whether they were high-profile tragedies , such as
those at Camber Sands, or smaller-scale events - is an important part of risk
management and is an approach that RoSPA has championed for many years.

In order to facilitate this learning, we believe a_ction is required nationally by
Government, particularly the clarification of duties held primarily by local authorities.

The Royal Society for the Prevention or Accidents
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(b) There appears to be no formal governance or control of risk management
requirements. Should the present, virtually voluntary, structure be examined?

We believe that the prevention aspects of the water safety system would benefit from
a review.

Currently, there is ambiguity in terms of who has responsibility for managing water
safety risks . The current prevention arrangements, particularly at a local level, are at
best difficult to understand and interpret. At worst, arguably, these can inhibit
possible duty holders from taking action to reduce risk.

It is important to stress that we do not believe these concerns extend to emergency
response arrangements, which are governed by the UK Search and Rescue (SAR)
framework.

Given that we believe that it is the prevention aspects of water safety that require the
most scrutiny, we have focused our response upon these elements.

Our understanding of the regulatory framework for England is as follows:

Local Authorities as landowners, occupiers or managers of sites which the public use
have duties towards staff under the Health and Safety At Work etc Act 1974
(HASW). Duties towards the public are created via Section 3 of HASW. In situations
where there is an "undertaking" within the meaning of Section 3, the duty-holder is
required to take "reasonably practicable" measures to address the risks created. To
what extent an undertaking exists and what are reasonably practicable responses
have developed in the courts.

Breaches of these duties can give rise to criminal liability for organisations and
individuals. The Health and Safety Executive (HSE) has set out a series of factors
which it applies in determining enforcement action for Section 3 risks generally 1, and
where natural features are a factor2

Occupiers or landowners have further duties towards visitors and trespassers on
their sites under the Occupiers Liability Acts 1957 & 1984. Breaches of these duties
give rise to civil liability which can result in court action and payment to make good.

Statutory responsibilities for local public health services are set out in the Health and
Social Care Act 2012. The associated outcomes framework establishes the national

1 http://www.hse.gov.uk/enforce/opalert.htm

2 http://www.hse.gov.uk/enforce/hswacl/docs/situational-examples.pdf

The Royal Societ y for the Prevention of Accidents
A company llmlled by gua,antee ieglstered In England with No. 231435
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priorities that local authorities are expected to work towards, alongside those set
locally. Reductions in accidents to children and young people, along with road
transport accidents, are monitored. There is no explicit mention of drowning harm in
the national framework 3
. Thus action is left to the local decision-makers to determine
if the issue needs consideration.

The Civil Contingency Act 2004 sets out duties upon local authorities, fire and rescue
services (FRS) and the Maritime and Coastguard Agency (MCA) as Category 1
responders to assess risk for areas for which they are responsible , and to work with
Category 2 responders such as the HSE. Locally, such action manifests in the form
of "integrated risk management plans" (IRMPs) through which some FRS, such as
East Sussex, address drowning harm from both the prevention and emergency
response aspect, as does the MCA nationally.

The effect of the above statutory framework is that we have a national system that is
well equipped to address drowning emergencies, after the fact, through the UK SAR
framework. Yet, one that is comparably poor at identifying and preventing the causes
of the fatalities.

Further, the existing statutory framework has evolved in such a way that it can ,
arguably, inhibit possible duty-holders from acting to reduce water safety risks, or
only take steps after a fatality in a reactive manner.

The effect is that moral or reputational risk arguments become the dominant factors
in the rationale to explore or address drowning risks proactively among duty-holders.

As you correctly note in your letter, charities such as RoSPA and RNLI, or executive
agencies such as the MCA and FRS, are then left to be the prime actors in reducing
or managing these risks.

Given the lack of clear duties, responsibilities and indicators, it is very difficult to
identify and mitigate risks ahead of time.

To address this, we suggest the following:

(i) That the Government undertakes a review of the current system of risk
management for the primary prevention of drowning harm, and how the UK
compares to other leading nations such as Australia, New Zealand, Canada,
Germany and Ireland, along with similar injury risk themes such as road traffic or fire
risks.

3 http://www.phoutcomes.info/

The Royal Society for the Prevention of Accidents
A company limlled by gua,antee ,eglsteied In £n gt•nd with No. 231435
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(ii) That the Government explores statutory options equivalent to those offered by
The Road Traffic Act 1988. A duty upon local authorities to assess and develop
measures to address water safety harm could be usefully explored. 4

(iii) Clarification should be sought from the Camber Sands local HASW enforcing
authority and the HSE on the issue of whether consideration was given to use of
existing enforcement powers under HASW with regards to these incidents

(iv) RoSPA is currently revising its water safety advice for owners and duty-holders of
inland waters. Subject to resources, we will look to review the equivalent advice for
coastal and beach environs by the end of 2018.

(i) Possible climatic effects

The findings of the Pitt Review in 2007 led to additional statutory powers and
operational changes as to how the country adapts and responds to climatic risks,
namely surface water flooding and coastal inundation events, such as those seen in
the summer of 2004 at Boscastle.

The local and national plans sit within civil contingencies frameworks as noted
earlier. The water-related risks within IRMPs typically are infrequent events that
affect multiple people, property and communities.

As noted earlier, we believe these plans to be robust for the risks they are seeking to
mitigate. However, they address different scenarios to those which account for the
majority of fatal drowning events.

Seasonal variations, such as periods of warmer weather and bank holidays, correlate
with both fatal and non-fatal incidents. In our opinion, this is most likely due to the
greater number of visits to open water spaces. RoSPA and members of the

Section 39 of the Road Traffic Act provides to the Secretary State for Transport and local authorities' powers to address road
safety. Including; 3(a) must carry out studies into accidents arising out of the use of vehicles, and; 3(c) must, in the light of those
studies, take such measures as appear to the authority to be appropriate to prevent such accidents.
(http://www.legislation.gov.uk/ukpga/1988/52/section/39)

The Royal Society for the Prevention of Accidents
Acompa ny llmlled by guarantee registered In England with No. 231435
Registered office: RoSPA Howe, 28 Calthorpc: Road, Edgbiuton, Birmingham, Dl S I RP
Registered Charity No. 207823

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NWSF plan prevention activities to coincide with these periods, and step-up
communication activity ahead of expected warm weather.

Effective beach mangers regularly manage these peaks, and plan
variations in service provision.

for these

(ii) Differences in ethnic origin and languages spoken by current visitors

Understanding and planning for the variety of demands that any group of visitors
present is a central competence for the effective beach manger. For example, kite
surfers will want different facilities and features to dog walkers or families, and will
require tailored approaches to minimise risks and disruption.

It has been understood for some time that a// visitors pay little attention to physical
safety information, at best spending seven seconds considering a signboard, for
example, and, further, that text-based approaches are less well comprehended by all
groups.

It is also well accepted that just providing information on hazards, does not
necessarily affect behaviour. For example, a study on the information provided on rip
currents at Bondi Beach, Australia, had no discernible positive, and sometimes a
negative, effect upon subsequent safety decisions and behaviours. 6

The risks of open-water - particularly temperature and cold water shock - are not
well understood within the general population. We believe this to be a principal
underlying factor in many drowning deaths. For this reason, raising general
awareness is a central ambition within the drowning prevention strategy.

Steps we have already taken include:

• The development of a UK and global standard for signs and symbols for water
safety, addressing some of the limitations outlined above (ISO 20712). These
have been designed in such a way that little or no country-specific language
skills are required. Comprehension testing was a part of the development
phase for these. The same symbols that are on now on British beaches can
be found in the USA, France and Japan etc.

Operational research and comprehension testing towards the UK and ISO standard sign development.

Operational research between academia and Surf Lifesaving Australia to support the development of the ISO standard.

The Royal Society for the Prevention of Accidents
A company limited by guarantee registered In England with No. 23 t 435
Registered office: RoSPA House. 28 Calthorpc Road, Edgbaston, Dirmingham, 915 I RP
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• The production of collective interpretation guides for the UK on "how to

implement" these standards

•

Improvements to the incident taxonomy for the WAID system, the UK's
drowning database, have been developed. These include more detailed
information on the person involved.

The extent to which ethnicity and language skills are a factor in drowning has not
been quantified in the UK. We are currently exploring the feasibility of studying these
factors. However, it is our understanding that information on these are not routinely
recorded at Inquest.

We note, from your letter and media reports, that four of the drowning victims were
undertaking education at college or university level.

We will report back on the feasibility of undertaking, or progress towards, a study of
the role of ethnicity and language skills as a contributory factor, either directly or in
conjunction with other members of the NWSF by the end 2017.

(iii) Constant and fast changes in communications with the public, which
everyone at this inquest agreed to be crucial to the educative process

We agree that being able to communicate using a variety of methods and
approaches is important, and have agreed a target within the strategy to address
this.

Further, we agree that ensuring that organisations are up to date with this is a critical
element of an effective beach management plan. As noted earlier, communications
that lead to positive behaviours are difficult and expensive to execute at scale.

There is already a significant amount of free or low-cost resources and insights
available.

The following is an overview of the opportunities at which the effective beach
manager could engage with visitors/potential visitors and the types of resources
available that could assist with this engagement:

•

In schools, most notably at Key Stage 2 through swimming and water safety
education, and aspects of the school PSHE framework . These are our only

The Royal Society for the Prevention of Accidents
A company limited by guaranlee reglslered In England wllh No. 231435
Rcglslcrod offfce: Ro5PA House, 28 Calthorpc Road, £dgbaslon, Birmingham, 815 l RP
Reglslered Charity No, 207823

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whole-populatio~ level measures available, and are covered in more detail
against your following point

• When potential visitors are researching/choosing a venue/activity, including by
"Googling" or using social media/websites such as Facebook, Twitter,
lnstagram etc. Campaigns such as the RNLl 's #RespectTheWater7 and HM
Coastguard's information films8 have reached millions of people.

•

Information and advice is reinforced en-route at service and train stations, on-
the radio and billboards, in pubs and tourist accommodation.

• On arrival at the venue, such as the car park and other bottlenecks, and again
at strategic points around the venue such as key footpath junctions. As
mentioned earlier, we have standardised the information that can be provided
at these points and provided free "how to" guides for managers. RoSPA also
provides training and support to
local authorities to help make rapid
improvements and to develop integrated plans.

• Face-to-face

information
coastguard or fire officer.

from a

trusted person , such as a

lifeguard,

Within the NWSF, steps have been taken to standardise and collectively approach
safety information campaigns, and to make readily available these resources to
beach and other managers.

For managers, events such as the RoSPA National Water Safety Conference, which
takes place every 18 months to two years, and publications such as RoSPA's
Leisure and Education Journal, which is produced quarterly, aim to provide useful
policy updates and practical guidance to those who work within water safety.

(iv) Improvement, considered vital, of education and awareness of coastal
dangers amongst children and those who Jive far from the sea.

As noted earlier, provision of swimming and water safety at Key Stage 2 is our only
truly population-level water safety intervention available in England. Approximately
50 per cent of children reach the required standard, leaving millions of school-aged
children without the requisite skills to improve survival chances .

7 www.respectthewater.com

• https://coastguardsafety.campaign.gov.uk/

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We continue to support Swim England and partners in their review of school
swimming, aimed at removing the barriers to participation 9

Primarily through the RoSPA National Safety Education Committee, we will continue
to develop, champion and inform the PSHE framework, which covers topics of
personal safety and resilience, and to call for PSHE to become a statutory
requirement.

(d) Resources and monetary considerations & Powers of the Coastguard

We would welcome further resources to address the burden of drowning, irrespective
of which governmental department or agency leads the initiative. RoSPA and
members of the NWSF maintain a positive working relationship with the MCA, with
support from the Secretary of State's for Transport's office.

The question of further powers, we feel, would be best answered by a review. In
order to address the drowning burden through national legislation and the extension
of powers, consideration would need to be given to urban and inland areas not
currently within the scope of the MCA.

(e) There was pessimism expressed that any measure could prevent most
deaths, only reduce them. In those circumstances should there be a
consideration by central government of taking powers to restrict public use?

We are very cautious of approaches that might result in the closure or restriction of
access to current public spaces without a publicly available safety case being made.

Significant landowners such as The National Trust or Canals and Rivers Trust
successfully manage sites that have significant hazards to the public without
noticeable impacts or blanket restrictions. It is also worth noting that landowners and
local authorities already close certain areas during cliff collapse or flood events.

Lifeguarded zones on beaches can be closed by use of the red flag system. Although
these cannot provide an absolute guarantee, deaths within lifeguarded locations are
extremely rare in the UK, and these are, in our opinion, the safest open water venues
to swim.

9 http://www.swimming.org/ assets/Swim_England_ Curriculum_ Swimming_and_ Water_ Safety _Review_ Group _Report_201 7. pdf

The Royal Society for the Prevention of Accidents
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lf any consideration is to be given to further regulatory powers that may have an
effect in terms of restricting access; we would prefer a model akin to the
Scandinavian countries or the Scottish access laws, establishing a balanced
package of rights and responsibilities. Useful lessons from the Countryside Rights Of
Way Act could be applied, in which occupier's liability was reduced and concurrent
access rights created.

We are happy for our response to be shared and published, and will report back to
you on the actions we have taken.

Yours Sincerely,

Leisure Safety Manager

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Response from Rother District Council (PDF)

Date: 

14 September 2017 

Alan Craze Solicitor (retired) 
HM Senior Coroner East Sussex 
31  Station Road 
Bexhill on Sea 
East Sussex TN40 1 RG 

Dear Mr Craze 

Rother 

District  Council 

Chairman of the Council 

Town Hall 
Bexhill-on-Sea 
East Sussex  TN39 3JX 

I am writing to  you further to your letter of 24 July 2017 written under the powers vested in 
you as Senior Coroner for East Sussex relating to the prevention of future deaths and the 
matters of concern raised by yourself with respect to the tragic loss of life at Camber Sands 
in July and August 2016. 

I understand the matters of concern you raise to be in summary: 

•  The opportunity for lessons learnt to  be shared with others on a national basis 
•  A possible lack of formal risk management arrangements for UK beaches in 

the face of many changes: environmental, social and demographic 

•  Communications and educational issues 
•  The impact of resource availability on decision making for safety at the coast 
•  The possibility of restricting public use of UK beaches for safety reasons 

I have also taken note of the helpful summary of risk management issues raised  by 
Professor Ball and attached to your report. 

You asked us to respond to your letter with details of action taken and  proposed in response 
to  your concerns. 

Further to the relevant inquests held  in 2016 and 2017, you  have received from us two 
reports setting out the policy and operational arrangements in place in respect of our beach 
management functions at Camber Sands, a number of ancillary reports and documents as 
 presented to the inquest in June 2017. 
well as the statements of
The documents in question are: 

 and 

1.  Rother District Council Report and appendices to HM Coroner East Sussex 

17 October 2016 

2.  Rother District Council Second report and appendices to  HM Senior 

Coroner March 2017 

3.  Witness Statement of Anthony Leonard 23 June 2017 
4.  Witness Statement of Robert Cass June 2017 

Fax(01424)787879 

•

www.rother.qov.uk 

 
 
 
 
 
 
 
 
 -2-

I will not repeat this information here but will update you on actions taken since the inquests. 

You will already be aware that the Council took the decision to work with the RNLI for the 
provision of a seasonal lifeguarding service at Camber Sands from May 2017. Co-operation 
between the Council and RNLI  has been very good and a successful service has been 
provided during the summer months. There have been a number of peak days at Camber 
Sands with  capacity crowds. These busy days passed uneventfully with both the lifeguards 
and the Rother beach patrol dealing with lost children, first aid and advising and informing 
visitors. We have been working together to evolve and modify services and expect to make 
a number of small changes to the dates of service and deployment of lifeguards for next 
year. 

We have incorporated the contribution of £50,900 (index-linked) to the RNLI  into our annual 
budget setting process and remain  under contract to the RNLI for lifeguard services until 
December 2019. 

I note the RNLI have also been asked to respond to your report. 

We have continued our policy of providing a seasonal beach patrol complementing the 
lifeguard service and comprising nine staff in support of the Coastal Officers at Camber 
Sands. We have used the learning from the incidents of 2016 to develop the staff training 
provided at the beginning of the season and the daily briefings. We have purchased two 
megaphones for the use of the beach patrol to assist in moving people from sandbars on an 
incoming tide as required. 

Similarly we have maintained the effective joint working arrangement with Sussex Police 
known as Operation Radcott. As previously reported , this deals with missing/found children, 
vulnerable people and public order incidents. Sussex Police are currently investigating the 
use of drones for public safety purposes and we have given permission for them to fly them 
over RDC land. Our regular end of season debrief is scheduled for 9 October 2017. 

The Deputy Coastal Officer is now a year round  post in  support of 
the continuity and resilience offered by this appointment to strengthen the beach 
management function . 

 and we expect 

The RNLI  provided us with a signage audit carried out to their internationally recognised 
standards,  involving the updating of existing safety signs in  line with the new lifeguard 
provision. These have been commissioned and will be installed shortly when conditions 
permit. In addition, we have purchased and installed two electronic dot matrix signs 
positioned at the main access points to the beach which have shown variable messages 
through the summer, with the option for messages in other languages. 

A new leaflet setting out safety advice to visitors has been handed out to visitors at Camber. 
A copy is attached for information. A poster of this information is on display in the public 
conveniences at both car parks and is therefore seen by a large proportion of the visiting 
public. We are investigating the translation of this leaflet into relevant languages . 

Fax(01424)787879 

•

www.rother.gov.uk 

 -3-

We have improved the management reporting of our beach operations by developing an 
online facility for staff to submit both weekly and incident reports within a template that 
meets reporting standards and which are then stored electronically for later retrieval as 
necessary. 

With regard to  your concern that information be shared with other relevant agencies, we are 
making a further presentation to the Local  Government Association's Coastal Special 
Interest Group on  18 September 2017 in London when we will share our learning with other 
councils from around the  UK coastline. We are of course willing to contribute to further 
awareness-raising and information-sharing initiatives. 

It is our intention to review and revise as necessary the Camber Sands Community Risk 
Assessment and Safety Plan with the assistance of the agencies represented on the 
Camber Beach and Water Safety Group. These agencies include RNLI,  National Water 
Safety Forum, MCA/HM Coastguard,  East Sussex Fire and Rescue Service, Sussex Police, 
South East Coast Ambulance service, Camber Parish Council and the LGA,  as well as a 
number of local businesses.  We are assisting the formation of a Camber branch of the RNLI 
in order to raise funds for the lifeguard service and raise awareness of water safety. 

Regarding the proposal for a more formal risk management process we feel quite strongly 
that a centralised or government-led approach to the issues of risk management around the 
extensive and varied  coastline of the UK would be difficult to achieve. Our experience 
prompts us to agree with  Professor Ball's finding that the task of risk assessment is  "best 
performed by those with intimate knowledge of the location".  Nonetheless, we would 
welcome any clarification that the Maritime and Coastguard Agency, especially HM 
Coastguard, is able to offer regarding support to local authorities in their role as beach 
operators. 

We are in agreement with you that the best approach to improving water safety around the 
coast (and elsewhere) lies in a more co-ordinated and better resourced approach to raising 
levels of awareness and education both of the public at large and of those with a 
professional or public service delivery role. We believe this risk based,  proportionate and 
evidence-based approach accords with that of the Health and Safety Executive with which 
we have recently been in consultation. As a small local authority with limited resources we 
are committed to nonetheless do all we can to assist this educational effort. The East 
Sussex Fire and Rescue Service under the leadership of Chief Fire Officer Dawn Whittaker 
have been a significant support to this work at Camber and across the county. Specifically 
the ESFRS have conducted a water safety campaign in  local schools and provided a team 
of safety advisors at Camber on busy days. 

Regarding the point about restricting access to part or all of certain beaches, we would 
advise that from our experience this would create a deal of public resistance were it to be 
introduced at Camber. There is an enormous amount of pleasure and wellbeing for people 
of all ages derived from year round access to the beach and sea in the Rother district. 
Taking this amenity away from the general public, even for short periods, may in our view be 
disproportionate, place new burdens on  beach operators and in the end probably prove 

Fax(01424)787879 

www.rother.qov.uk 

 -4-

unworkable.  Regarding the question of proportionality, from 
probability and  risk we derive the finding that between the Council's formation  in  197 4 and 
2012 there will have been a minimum of 38 million visitors,  and potentially up to 50 million, 
to Camber Sands with no drownings. 

 calculations of 

We would of course implement a beach closure in exceptional circumstances to protect the 
public and when directed to do so for instance by the police.  In addition we have used the 
2012 byelaws to zone off the extreme sports area at Broomhill Sands for safety reasons. 

As part of our corporate governance and the requirements for accountability and scrutiny, 
officers of the council have compiled a comprehensive report to our Audit and Standards 
Committee. The report will be in the public domain a week before the committee meets on 
27 September 2017 when Members of the Council will be invited to debate its contents and 
propose any further actions they deem necessary to meet our obligations at Camber Sands. 
A draft copy of the report is attached for your information. 

We would emphasise again that the tragic loss of life at Camber Sands on 24 July and 24 
August 2016 is a matter of deep regret and we extend our sincerest sympathies to the 
bereaved families. 

I hope that the foregoing meets your requirements.  Please do not hesitate to get in touch 
with myself or officers of the council to discuss these points or request further information. 

Yours sincerely 

Chairman 
Rother District Council 

Enclosures:  Camber safety leaflet 

Draft report to RDC Audit Committee 27 September 2017 

Fax(01424)787879 

www.rother.gov.uk 

CflVD

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Response from Royal National Lifeboat Institution (PDF)

1Drll 
Lifeboats 

Mr Alan Craze 
H.M.  Senior Coroner for East Sussex 
31  Station Road 
Bexhill-on-Sea 
East Sussex 
T40 1RG 

13 September 2017 

Royal National Lifeboat Institution 
West Quay Road, Poole,  Dorset, BH1 5 1HZ 
Tel 0845122 6999  Fax 0845 1261999
info@rnli.org.uk  RNLl.org 

Patron: Her Majesty The Queen 
President  HRH The Duke of Kent J(G 

RNII(fo:uhng) lld 01073377, RNI I(Salt,) ltd 2ZOZ2•«>    RNU l£ntt1prbt)) Ltd 178-4500 
Jlt~II <ompariu rt&hlttfd at Wu t Qtu y Road, Ponlt , Dor.set, 8H1S lttZ 

From: 
RNLI Chief Executive 

Re: 

Kenugen SATHTHIYANATHAN (deceased) 
Nitharsan RAVI (deceased) 
Kobikanthan SATHTHIYANATHAN (deceased) 
lnthushan SRISKANTHARASA (deceased) 
Gurushanth SRITHAVARAJAH (deceased) 
Gustavo SILVA DA CRUZ (deceased) 
Mohit DUPAR (deceased) 

Thank you for your letter dated 24 July 2017 under Rule 43  regarding the above matter. 

Background 

The RNLI  declares its lifeboat response to the UK Government through the  UK Search and 
Rescue Strategic Committee. This forms a part of our Concept of Operations and its 
Strategic Performance Standards.  The lifeboat service that the RNLI provides enables the 
UK Government to meet its obligations under International Conventions for saving lives at 
sea. 

In our Concept of Operations, we also state that we will provide a lifeguard service on  a 
seasonal basis, a prevention and education service along with a flood rescue capability. 

The RNLl's lifeguard service was first trialled  in  2001. This trial  was  successful and  its wider 
introduction  started  in  2002.  Since  then,  a  progressive  rollout  plan  has  been  followed  and 
this  year 249 lifeguard units were operational around the UK during the summer season. We 
plan  to  continue  that roll  out  plan  as  a  part  of our strategy to  reduce  drowning  but we  can 
only establish  new lifeguard units with  the express permission of the  relevant local authority, 
landowner, beach owner or operator. This is a limitation on our ability to provide the service. 

In  order to  determine  where  lifeguard  units  should  be  provided  and  for what season  length, 
the  RNLI  has  developed  a  beach  risk  assessment  service  that  is  free  to  local  authorities, 
land  owners  and  beach  owners/operators.  However,  the  risk assessment and  the  outcome 
recommendations  are  purely  advisory.  It  is  for  the  local  authority,  land  owner  or  beach 
owner/operator to then decide whether to  implement the recommendations. There is no legal 

The RNLI  is the charity that saves lives at sea 

Royal National lifeboat Institution, a charity registered in England and Wales (209603) 
and Scotland (SC037736). Registered charity number 20003326 in the Republic of Ireland 

 
 
 
 
 
 
 
 
 
 
 
 obligation  for  the  RNLI  to  provide  the  risk  assessment  service  and  we  do  not  have  any 
enforcement powers concerning whether its recommendations are implemented. 

The current business plan sets out the RNLl 's organisational strategic goal to  reduce coastal 
fatalities by 50% by 2024 in the UK and Ireland. 

The RNLl's response to your concerns and our action  points concerning them are as follows: 

a)  There  are  possibly  lessons  learnt  in  the  circumstances  of  and  the  issues 
surrounding these deaths which may be of help to others on  a national basis. 

The RNLI  agrees and  understands the  importance of learning lessons that can  be  of 
help to others on a national level. 

Action  taken  - The  RNLI  draws  on  fatality data  and  its  root  cause  analysis  from  the 
National  Water  Safety  Forum's  (NWSF)  Water  Incident  Database  (WAID).  The 
evidence  from  that database (and  from  our own and  open  source data) helps  inform 
the  content of our annual  national downing  prevention  campaign  known as  'Respect 
the  Water'.  Learning also informs local campaigns and targeted messages  to  'at risk' 
groups.  This  action  has  been  underway  for  a  number of years  and  also  delivered 
through  our  membership  of  the  NWSF,  our  support  of  the  National  Drowning 
Prevention Strategy and our other partnership and  influencing work at a national and 
local  level.  Specifically,  our  campaign  and  messages  content  is  updated  on  a 
continuous  review  basis,  with  improved  data  collection/analysis  and  impact  metrics 
under development.  We will  continue with  this work in  pursuit of our strategic goal to 
reduce  accidental  coastal  drowning  by  50%  by  2024.  We  share  our  findings  with 
partner  organisations,  encourage  them  to  support  our  national  messaging  and  we 
support their prevention work too. 

b)  There appears to be no formal  governance or control of risk management 

requirements. Should the present, virtually voluntary, structure be examined? 

While there is significant governance around the requirements for risk assessment 
under the Health and Safety at Work Act;  what is unclear is the question of who has 
responsibility for beach safety or, more specifically, the in-water safety of beach 
users. 

There are  no formal statutory requirements which prescribe required specific control 
measures. There is informal guidance in the form of ISO and British standards and 
publications such as 'Safety on Beaches' 

Clarification of the responsibility for safety on beaches has previously been identified 
as an issue that needs to be addressed. 

Greater clarity is needed about the duty of care owed by those responsible for 
beaches around our coastline and the RNLI would like government clarification 
concerning this. 

 Action taken - The RNLI is not in a position to examine the formal governance of 
beach safety risk management on  behalf of the nation. We would welcome a review 
and  believe that local authorities,  landowners and beach owners/operators should 
have a more clearly defined obligation for the risk management of their beaches and 
to act on risk assessment outcomes.  This,  in our opinion would reduce the likelihood 
of accidental drowning occurring in the beach environment. 

Could perhaps the Marine (Maritime) and Coastguard Agency,  who have 
enforcement powers akin to those of the Police, be given more resources and 
take a bigger role than they currently have? 

MCA enforcement powers relate to the Merchant Shipping Act and other legislation 
rather than for beach safety. The RNLI works closely with the MCA in promoting 
beach safety and drowning reduction efforts. If more resource for this effort was 
made available to the  MCA then the RNLI would welcome that. 

Action taken -The RNLl's charitable activity to improve safety at Camber Sands has 
led to  the provision of a 2017 lifeguard service there which  we are able to provide 
next year and well into the future on  the proviso that Rother District Council requests 
us to and supports our service . This service includes offering face to face beach 
safety information and literature as well.  Other aspects of beach safety there are 
informed by the risk assessment and we believe it is for them to ensure the 
necessary resource is available to implement the identified  risk control  measures. 

Changes include: 

1.  Possible climate change effects; 

2.  Differences in ethnic origins and language spoken  by current visitors; 

3.  Constant and fast changes in means of communication with the public, which 

was agreed to be crucial to the educative process; 

4. 

Improvement; which is considered vital for education and awareness of costal 
dangers amongst children, and those who live far from the sea. 

Climate effect 

The  evidence  would  suggest  that  annual  fluctuations  in  weather  and  daily/weekly 
local  weather conditions  have  a  greater influence  on  beach  safety  than  changes  in 
climate change. 

Action  taken - The  RNLI  monitors  weather and  works  with  the  Met  Office. Weather 
dependant messaging is already in  use and we actively work with  media  outlets  that 
are able to distribute weather dependent messages to beach users. 

Ethnic and language barrier considerations 

Action  - The  RNLI  is  already  taking  action  to  identify  at  risk  groups,  and  the  most 
effective  means of communication  of safety messages.  At risk  groups include ethnic 
groups and those that are likely to  have language barriers. 

 Communication 

Action  taken - The RNLI uses digital platform tools,  modern advertising methods and 
face  to face  communication  as  methods  to  communicate  with  the  beach  going  and 
wider  public.  We  monitor  the  effectiveness  of  our  communications  and  work  with 
other organisations to make the best of combining our resources with others. 

Education and awareness of coastal dangers 

Evidence  from  countries  that  have  introduced  comprehensive  programmes  to 
improve the  populations  swimming ability demonstrates a significant reduction  in  the 
risk of drowning. 

Action  taken  - The  RNLI  and  its  partner  organisations  that  support  the  National 
Drowning Prevention Strategy are committed to increasing education  and awareness 
programmes . Particularly to children and their knowledge of coastal  and  inland water 
dangers. The  RNLI  is  an  advocate of this target in  the  National Drowning Prevention 
Strategy  and  supports  the  Schools  Swimming  Review  recommendations  that  have 
been  presented  to  Government this  year.  The  RNLI  has  comprehensive educational 
and  awareness  programmes  which  are  delivered  through  the  RNLI  staff  and 
volunteer network and in  partnership with others. This work will continue and grow in 
order to reduce the likelihood of accidental drowning, both inland and at the coast. 

The  RNLI  would  also  add  that the  way that people are  using  the  sea  appears  to  be 
changing , with  more people engaging in  a wider  variety of water-based  activities  in, 
on and around the water. 

The  RNLI  has  already  created  a  series  of evidence  based  'activity  risk  profiles'  to 
identify  the  at  risk  groups.  Messaging  to  these  groups  is  in  progress,  raising 
awareness  and  influencing  behaviour  change.  This  work  will  continue  and  develop 
further over the coming years. 

c) 

Inevitably resource and monetary considerations affect decision making by 
those charged with safeguarding people like the seven who died here. Perhaps 
that is  another reason why a review of the current system may well be needed. 

Resource and monetary considerations will always be a factor in  decision making. 

Action taken - The RNLI carries out the risk assessment of beaches free of charge.  If 
the risk assessment outcomes lead to the RNLI providing a lifeguard  service,  then 
the RNLI will fund the provision of that service but with a contribution from  the local 
authority,  landowner or beach owner/operator to an agreed level of service.  No direct 
overhead, training or equipment costs are passed on . We believe appropriate 
budgets for beach safety should be set by those responsible for their beach 
operation, in  order to implement the necessary control measures identified by the risk 
assessment. 

d)  There was pessimism expressed at the inquest that any measure could prevent 
most  deaths,  only  reduce  them.  In  those  circumstances,  should  there  be 
consideration  by  central  government  of taking  powers  to  restrict  public  use, 
according to  daily circumstances,  of part or all of certain  beaches? Certainly a 
localised  study,  on  a  national  model,  should  be  carried  out.  I  believe  it  has 
elsewhere in the world. 

 Lifeguards  already  utilise  a  'red  flag '  option  which  works  effectively  in  informing 
swimmers of the  dangers of entering the  water.  This procedure  has a very high level 
of compliance.  Closing  a section  of beach  carries the risk  of transferring the problem 
to  other beaches;  where  no  beach  safety services  may exist,  and  is  therefore  used 
sparingly.  Large scale beach closures would be difficult,  if not impossible, to  enforce, 
and  would  require  supporting  legislation.  It  would  be  reasonable  to  question  the 
appetite of law-makers  to  pass  legislation  that would  restrict people  from  accessing 
the beach. 

Action taken  - The RNLI recommends that landowners are  responsible of 
implementing a range of appropriate control measures at beaches.  If lifeguards are 
present as a part of these control measures, the areas outside of the lifeguarded 
area must be given due consideration too.  It is very important to recognise that a 
lifeguard service cannot be the only preventative measure on  UK beaches. 

There  is  no  absolute  guarantee  that  control  measures  (such  as  lifeguarding)  could 
prevent  any  particular  incident.  But  it  is  crucial  to  recognise  that  lifeguards,  where 
identified  as  a  control  measure,  significantly  reduces  risk  to  those  who  'swim 
between the flags '. 

Thank  you  for  the  opportunity  to  respond  to  your  concerns.  I  believe  the  actions 
already  underway  through  the  Institution's  work  will  lead  to  fewer  drownings  and 
serious incidents on the nation's beaches. 

I  would  like  to  stress  though  that  it  is  imperative  that  risk  assessments  are 
undertaken and acted on,  with those responsible for the implementation being clearly 
identified  and  held  to  account  for  inaction.  Without  this  imperative  being  achieved, 
people will needlessly and tragically lose their lives. 

Chief Executive

The report

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