Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0364, written 4 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Oct 2023 |
|---|---|
| Reference | 2023-0364 |
| Deceased | Kellie Poole |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| Category | 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Health and Safety Executive Redgrave Court Merton Road Bootle Merseyside L20 7HS 1 CORONER I am Peter Nieto, senior coroner for the coroner area of Derby & Derbyshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 28 April 2022 I commenced an investigation into the death of Kellie Jean POOLE aged 39. The investigation concluded at the end of the inquest on 27 September 2023. 4 CIRCUMSTANCES OF THE DEATH Kellie died on 25 April 2022 on the river bank of the River Goyt near to Whaley Bridge in Derbyshire. She had collapsed in the river whilst participating in a led session of cold water immersion. On the evidence it is likely that the cold water triggered her heart to go out of rhythm which then led to her sudden cardiac death. On post mortem examination it was identified that Kelly had an abnormal heart, although she had never been diagnosed with or suspected to have a heart condition. It is likely the heart condition prevented recovery from the heart dysrhythmia. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I emphasise that the matters of concern do not relate specifically to the circumstances of Kellie’s death. It appears that there is increasing public interest and participation in cold water immersion. Businesses have been established which offer led cold water immersion sessions and may offer other types of led activities such as breath work often in combination with the cold water immersion. As businesses they charge participants a fee for the sessions. Regulation 28 – After Inquest Document Template Updated 30/07/2021 It is recognised that some people may experience an adverse physiological reaction to cold water immersion, which has the potential to be life-threatening. Whilst many leisure or health focussed activities may carry risk, where these are provider led the general expectation must be that participants are informed of risks, have an expectation that reasonable safety measures are in place, and that the provider has suitable training and experience. There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance. Some sessions take place in water tanks, but sessions are also held in open water such as rivers, lakes, and reservoirs, and therefore at locations that may in themselves pose risk. Session leaders may have undertaken some form of training, but I am not aware that the nature and quality of the training itself is regulated/quality assured. There is no established UK member organisation for providers of cold water immersion, other than for ‘wild’ and open water swimming which is a distinct activity, and therefore no form of even voluntary self-regulation. On my understanding the current limits of oversight of cold water immersion providers in effect means that these activities have not received guidance from the Health and Safety Executive or other appropriate bodies. My investigation indicated that local authority environmental health departments are unclear whether they should and how they might monitor and oversee these providers. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 29, 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 Interested Persons (partner) (owner of Breatheolution) I have also sent it to (Principal Environmental Health Officer Staffordshire Moorlands District Council/High Peak Borough Council) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 04/10/2023 Peter Nieto Senior coroner for Derby & Derbyshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Health and Safety
Executive
Head of Local Authority & Safety Unit
Engagement and Policy Division
2, Victoria Place
Carlisle
CA1 1ER
Mr P Nieto (Senior Coroner)
Derbyshire County Council
Coroner’s Court
Town Hall
Chesterfield
Derbyshire
S40 1LP
Reference
Date 28th November 2023
For the attention of Mr Peter Nieto, Senior Coroner
Dear Sir
REGULATION 28 PREVENTION OF FUTURE DEATHS – COLD WATER IMMERSION
Thank you for your Regulation 28 report to Sarah Albon, HSE Chief Executive, in relation to the death
of Ms Poole while participating in a cold water immersion activity. I am responding as the Head of Local
Authority and Safety Unit at the Health and Safety Executive (HSE) which holds the operational policy
lead for health and safety regulation of the leisure sector.
Your report raises as matters of concern, that cold water immersion providers have not received
guidance from HSE or other appropriate bodies and that local authority environmental health
departments are unclear whether they should and how they might monitor and oversee these providers.
Providers of cold water immersion services to the public are required to comply with the Health and
Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999.
This legislation provides a framework for securing health, safety and welfare by requiring businesses
providing cold water immersion services to identify risks to their workers and customers from their
activities and to take action by putting in place suitable measures to manage those risks.
Businesses are also required to appoint a competent person(s) with the skills, knowledge and
experience to recognise hazards and to assist with putting into place effective measures to protect
workers and others from harm. There is no legal requirement for businesses to hold public liability
insurance or to make first aid arrangements for customers. HSE does, however, strongly recommend
that non-employees are included in assessments of first aid needs and that provision is made for them.
When assessing and managing risk, businesses should take account of relevant guidance. To help
businesses comply with the law, HSE provides general guidance on health and safety such as HSE’s
health and safety basics for your business (https://www.hse.gov.uk/simple-health-safety/index.htm) as
well as targeted guidance for higher-risk industries and activities. HSE does not seek to provide
guidance for all industries and activities as it is often the case that others are more knowledgeable or
better placed to provide such guidance.
The risks associated with open water and cold water shock are well known and relevant guidance is
available from multiple authoritative sources such as the RNLI (https://rnli.org/safety/know-the-
risks/cold-water-shock) and the National Water Safety Forum
(https://www.nationalwatersafety.org.uk/adviceresources/open-water-swimming). In addition, guidance
is also widely available from local authorities and the emergency services such as that provided by
Staffordshire Moorlands District Council (https://www.staffsmoorlands.gov.uk/article/6759/Safety-
around-open-water) and Staffordshire Fire and Rescue Service
(https://www.staffordshirefire.gov.uk/your-safety/safety-outside/water-safety/).
It is HSE’s view that the regulatory provisions in place requiring cold water immersion providers to
manage risks, together with the guidance available from multiple sources on the main risks involved,
provide a suitable basis for businesses to provide activities safely and for local authorities to take
regulatory action where required. Consequently, HSE will not be publishing specific guidance at this
time for cold water immersion activities. However, as this is a newly emerging leisure pursuit we will
keep this activity under review.
HSE will continue to support and liaise with our regulatory partners in local authorities who are
predominantly responsible for the enforcement of work related health and safety legislation in this area.
To increase awareness among local authority enforcement officers I have asked that this matter is
raised at the national Local Authority Health and Safety Practitioner Forum
(https://www.hse.gov.uk/lau/national-committees.htm).
I hope that the above information addresses the matters raised.
Yours faithfully
Head of Local Authority and Safety Unit
2
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