Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0335, written 22 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Aug 2023 |
|---|---|
| Reference | 2023-0335 |
| Deceased | Lawson Bond |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Chief Executive, Wychavon District Council, Civic Centre, Queen
Elizabeth Drive, Pershore, Worcestershire WR10 1PT
1 CORONER
I am David Donald William REID, HM Senior Coroner for Worcestershire.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 22 April 2022 I commenced an investigation and opened an inquest into the death
of Lawson Bond, a child of 2½ years of age. The investigation concluded at the end of
the inquest on 21 August 2023.
The conclusion of the inquest was that Lawson died as the result of misadventure.
4 CIRCUMSTANCES OF THE DEATH
In answer to the questions “when, where and how did Lawson come by his death?”, I
recorded as follows:
“On 28.3.22 Lawson Bond was attacked and mauled by an adult Rottweiler at his
home in Egdon. The Rottweiler was in a field at the address, to which Lawson had
gained access from his garden by climbing a gate and unhitching a security chain. He
was taken to Worcestershire Royal Hospital, and then to Birmingham Children's
Hospital, where he died from his injuries on the morning of 30.3.22.”
The Rottweiler which mauled Lawson was one of eight adult Rottweilers kept by
Lawson’s grandmother
business breeding Rottweilers and advertising Rottweiler puppies for sale. She ought
to have obtained a licence to carry out these activities, as per The Animal Welfare
(Licensing of Activities Involving Animals) (England) Regulations 2018, but had never
had one.
had been running a
. For many years,
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. –
(1) In evidence to the inquest,
, Principal Licensing Officer in the
Licensing Team at Worcestershire Regulatory Services, agreed that the
Licensing Team has a role in trying to identify unlicensed breeders, but stated
that in this respect the Team is “intelligence-led”, i.e. that they will only act on
1
information received or complaints made. Whilst the Team has an intelligence
officer who will monitor websites, such monitoring will only take place in
response to information received or a complaint made. The Team does not
take a more pro-active approach generally, for example by searching
websites and social media on a regular basis;
(2) The inquest received evidence from staff at the Worcestershire Coroner’s
Office, who had undertaken two separate internet searches looking for
Rottweiler puppies for sale within the Worcestershire area. These searches
were conducted on 9 June 2023 and 28 June 2023, and found recent adverts
placed by
on two separate websites
sale. An identically worded advert was also found in the name of
accepted in evidence that this advert was
), advertising Rottweiler puppies for
placed on her behalf;
(3) It might be thought that a regulatory authority would have less reason to be
concerned about a scrupulous dog breeder, who applies and pays for a dog
breeding licence, than about a dog breeder who ignores the licensing
scheme. It is therefore concerning that Worcestershire Regulatory Services
does not, at present, take a more pro-active approach in this regard, for
example by monitoring websites for adverts placed by those selling puppies
within its area. It would be quite possible to specify searches in such a way as
to concentrate on breeds which might give a greater cause for concern in
terms of safety.
For all of the above reasons, I am concerned that unless Regulatory Services within
Wychavon District Council take action, there will remain a risk that unscrupulous
unlicensed breeders will continue to offer puppies and dogs for sale within the
Wychavon area, which present a heightened risk of danger to those who buy them
and who come into contact with them.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that you,
as Chief Executive of Wychavon District Council, 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 13 November 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 Chief Coroner and to the following:
(a)
(b)
(c)
, Lawson’s mother;
, Lawson’s father;
, Lawson’s grandmother, who had Interested Person status for the
purposes of the inquest.
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
2
your response, about the release or the publication of your response by the Chief
Coroner.
9
22 August 2023
David REID
HM Senior Coroner for Worcestershire
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
WYCHAVON Wychavon District Council, Civic Centre, Queen Elizabeth Drive, Pershore, Worcs. WR1 0 1 PT 10 November 2023 Mr David Reid HM Senior Coroner for Worcestershire Dear Mr Reid REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Wychavon District Council understands your concerns set out in the Regulation 28 Report dated 22 August 2023 relating to the tragic death of Lawson Bond. Historically, the Worcestershire Regulatory Services (WRS) Intelligence Team has undertaken project based proactive monitoring, for a fixed period of time, of a number of the most prominent selling sites on the internet known to be used by unlicensed breeders. This has been successful, identifying 30 unlicensed breeders across Worcestershire. The breeder in this particular case generally advertised on a site not covered by the project work as it had not featured in previous intelligence gathering. Going forward from this month, for a minimum period of 12 months, the intelligence gathering project for Wychavon will be a continuous, business-as-usual activity. The work will cover a significantly larger number of key selling sites and we will ensure that the on-going intelligence gathering activity includes searches for the approximately 65 breeds classed as "large" by the Kennel Club and, guided by the expertise of the Dog Warden Team, any similar breeds that might meet these criteria. We will review the outcomes of this work at the end of this initial 12-month period with a view to continuing if successful. We would also respectfully suggest that specialist internet selling sites which routinely deal with breeders, particularly breed-specific sites, should have their own controls in place to ensure that those advertising who meet the "business" threshold are licensed. We understand that a number do this, refusing to take adverts from people who they believe ought to be licensed and are not. However, this does not stop individuals potentially creating new accounts or using different names to avoid controls. Although it is not perfect, we would ask you to encourage those taking adverts to maintain a robust position with those they believe are acting in the course of a business. Please do not hesitate to contact me again if I can provide anything further. Chief Executive ACHIEVEMENT AWARDS 2017 r:; tJ W WYCHAVON lu; II i::=01STRICT COUNCIL J;;> w I'll a;~ w . good services, good value
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