Prevention of Future Deaths reports · 2023

Sandra Curran

Regulation 28 report to prevent future deaths, reference 2023-0378, written 9 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Oct 2023
Reference2023-0378
DeceasedSandra Curran
CoronerAlison Mutch
Coroner areaManchester South
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1)  Foreign, Commonwealth and Development Office 
2)  ABTA – The Travel Association 

1  CORONER 

I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester 
South 

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 14th  July 2022 I commenced an investigation into the death of Sandra 
Curran. The investigation concluded on the 5th  June 2023 and the conclusion 
was one of Accidental Death. The medical cause of death was 1a) Apshyxia; 
1b) Drowning 

4  CIRCUMSTANCES OF THE DEATH 

On 4th  July 2022, Sandra Curran was snorkelling in the sea adjacent to the 
beach in Bugibba Saint Paul's in Malta. Concerns were raised about her 
appearing to be no longer moving. She was brought to the beach where she 
was unresponsive. An investigation in Malta found she had died from asphyxia 
as a consequence of drowning. 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to 
concern. In my opinion there is a risk that future deaths will occur unless action 
is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  – 

The inquest heard the Mrs Curran had booked her holiday through a UK Tour 
operator. Mrs Curran was not a strong swimmer and that she was unaware of 
the risks that swimming/snorkelling in the sea off the coast of Malta could 
present. No warnings were given in the welcome information/briefing about the 
challenge the sea around the coast in Malta could present to a weak swimmer. 
Previously when she had snorkelled it had been in far easier conditions where 

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 the risks of strong currents had not been present. The evidence given by her 
family at the inquest was that had her tour operator highlighted the need for 
caution Mrs Curran would not have snorkelled alone in the area where she 
drowned. A more proactive approach by UK tour operators highlighting the risk 
of getting into difficulties and how to mitigate them would reduce the risk of 
further deaths in circumstances such as Mrs Curran’s. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 4th  December 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 namely 
who may find it useful or of interest. 

 on behalf of the Family, 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or 
summary form. He may send a copy of this report to any person who he 
believes may find it useful or of interest. You may make representations to me, 
the coroner, at the time of your response, about the release or the publication of 
your response by the Chief Coroner. 

9  Alison Mutch 

HM Senior Coroner 

09.10.2023 

2

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Abta (PDF)
Alison Mutch 
Senior Coroner for the Coroner Area of Greater Manchester South  
HM Coroner Manchester South 

By email only 

Dear Ms Mutch,  

14 November 2023  

Thank you for your letter regarding the sad death of Sandra Curran in July 2022. We write in 
response to your Regulation 28 Prevention of Future Deaths report. We have carefully reviewed the 
report and your request for action. 

I thought it would be helpful to firstly outline the purpose and role of ABTA.  We are a trade 
association representing and providing services to our members, who make up a significant part of 
the UK travel industry and who sell a range of travel services including package holidays, flights, 
accommodation, and car hire. ABTA provides services to consumers through our customer support 
and arbitration services which deal with a range of consumer issues involving ABTA members. 

ABTA also fulfils a self-regulatory role in respect of its members through its Code of Conduct and 
financial protection mechanisms. Concerning health, safety and security, we provide guidance to 
members and raise awareness on safety issues with consumers and destination authorities.  

I should point out, however, that there are many travel providers who are not ABTA members.  Any 
company that is not an ABTA member would not have access to the advice and guidance we provide 
to our members on health and safety matters, or other topics.  In addition, UK travellers could visit 
Malta without using a UK travel agent or tour operator (either ABTA member or otherwise) to make 
their travel arrangements. 

ABTA regularly convenes a committee of Health and Safety leads from UK tour operators. We bring 
them together to discuss and review incidents and issues that consumers have faced while on 
holidays, using evidence-based information to shape guidance to members and consumers. We also 
work with consultants and external stakeholders, such as the FCDO, to help consumers avoid issues 
overseas.  

You draw attention in section 5 of your report to challenges that the sea around the coast in Malta 
could present to a weak swimmer, and suggest that a more proactive approach by UK tour operators 
highlighting the risk of getting into difficulties and how to mitigate them would reduce the risk of 
further deaths in circumstances such as Mrs Curran’s. We note that your report is also addressed to 
the Foreign, Commonwealth & Development Office (FCDO).  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ABTA’s Code of Conduct says that before a contract is made members should advise their clients of 
the availability of any advice issued by the FCDO. The current travel advice for Malta 
(https://www.gov.uk/foreign-travel-advice/malta) contains the following information on the Safety 
and Security page: 

Swimming safety 

During the summer, most beaches are patrolled by lifeguards with a flag safety system. Make sure 
you understand the system and follow any warnings; red flags indicate dangerous or hazardous 
conditions. Swim within designated zones and take extra care if there are no lifeguards, flags or 
signs. 

Follow local advice if there are jellyfish. 

See more information from the Malta Tourism Authority. 

ABTA runs a number of consumer campaigns where evidence from our members has highlighted 
that increased awareness on particular issues is important. We have been raising the importance of 
swim safety to consumers for over 20 years, and have been running a dedicated campaign on swim 
safety for around 10 years. 

We usually run proactive PR and social media campaigns in advance of the summer and winter peak 
seasons which have in the past achieved broadcast, national and trade coverage. Our 
communications team also deals with many incoming enquiries throughout the year, often during 
the summer when holidaymaker accidents make the news.  

We produce consumer safety information leaflets which highlight core safety and security advice.  
These leaflets are available to consumers who visit the ABTA website, and for our members to share 
with their customers, either in printable PDF or mobile-friendly format. By way of example, a news 
item from 30 June 2022, encouraged members to share these useful tips: 
https://www.abta.com/news/helping-keep-your-customers-safe-holiday 
https://www.abta.com/tips-and-advice/staying-safe-on-holiday/safe-and-healthy-holidays-sun 

And in 2023, we used #WaterWise to promote updated swim safety advice: 
https://www.abta.com/news/abta-urges-holidaymakers-be-waterwise-summer 
https://www.abta.com/tips-and-advice/staying-safe-on-holiday/swim-safe 

The messaging of the swim safe information includes the following: “Even if you regularly swim in a 
pool, don’t forget that open water swimming can be much more challenging”.  

Our members have a range of business models, so not all have representatives based in destination 
who would be able to offer advice on local conditions. 

We remain committed to providing guidance on swim safety, through our website and social media 
campaigns. We will continue to work with our members and other stakeholders to make this 
guidance available to travellers. 

 
 
 
  
 
 
 
 
 
 
 
 We are not aware of the full facts in the specific case which is the subject of your report and 
therefore we are unable to comment on the particular circumstances surrounding the tragic death 
of Mrs Curran. We wish to offer our sincere condolences, through your office, to the family and 
friends of Sandra Curran. 

Yours sincerely, 

Chief Executive
Response from Foreign Commonwealth and Development Office (PDF)
Deputy Director, Head of 
Strategy and Network 
Department, Consular and 
Crisis Directorate 
Foreign, Commonwealth & 
Development Office 
King Charles Street 
London  
SW1A 2AH 

www.gov.uk/fcdo 

Coroner’s Court  
1 Mount Tabor Street  
Stockport  
SK1 3AG 

Friday, 01 December 2023 

Dear Coroner, 

I am writing in response to your report dated 9 October 2023, following the investigation, 

concluded on the 5th June 2023, into the death of Sandra Curran on 4 July 2022 in Malta. 

I am replying as the Head of Strategy & Network Department, Consular and Crisis 

Directorate at the Foreign Commonwealth and Development Office.  

We welcome the opportunity to inform you of action we have taken in response to your 

report, and of our ongoing work supporting efforts to prevent similar tragedies. In doing 

so we again express our sincere condolences to the family and friends of Mrs Curran. 

In your report, you note the following area of concern: 

The inquest heard the Mrs Curran had booked her holiday through a UK Tour operator. 

Mrs Curran was not a strong swimmer and that she was unaware of the risks that 

swimming/snorkelling in the sea off the coast of Malta could present. No warnings were 

given in the welcome information/briefing about the challenge the sea around the coast in 

Malta could present to a weak swimmer. Previously when she had snorkelled it had been 

in far easier conditions where the risks of strong currents had not been present. The 

evidence given by her family at the inquest was that had her tour operator highlighted the 

need for caution Mrs Curran would not have snorkelled alone in the area where she 

drowned. A more proactive approach by UK tour operators highlighting the risk of getting 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 into difficulties and how to mitigate them would reduce the risk of further deaths in 

circumstances such as Mrs Curran’s. 

Action Taken  

1. 

 FCDO Travel Advice 

FCDO Travel Advice aims to provide objective information and advice to help British 

nationals make informed decisions about travelling abroad. We keep our Travel Advice 

under regular review to ensure it reflects our up-to-date assessment of risks and contains 

information relevant to British nationals.  We encourage British nationals to read our 

Travel Advice and sign up for alerts to see when the advice changes.  

In light of your report, we have considered further our advice on water risks in Malta:  

In July 2022, the Travel Advice read: 

Swimming 

During the summer, many beaches are patrolled by lifeguards and operate flag safety 

systems. You should make sure you understand the system and follow any warnings; red 

flags indicate dangerous or hazardous conditions. You should swim within designated 

swimming zones and take extra care if there are no life-guards, flags or signs. Follow 

local advice if jellyfish are present.  

You can find more information and a general code of conduct for beaches in Malta on the 

Malta Tourism Authority website 

In response to the report, the Travel Advice on swimming safety has been enhanced to 

include a link to the Royal Life Saving Society’s (RLSS) “Water Safety on Holiday” page 

in the “Swimming safety” section of the “Safety and Security” page. 

The FCDO’s established public-facing Travel Aware communications campaign will 

continue to prompt British nationals who are planning to travel abroad to read the latest 

FCDO travel advice for their destination and to sign up for e-mail alerts. 

The Foreign, Commonwealth and Development Office holds and uses data for purposes notified to the Information Commissioner under the 
General Data Protection Regulation and Data Protection Act 2018 (which may be viewed at www.informationcommissioner.gov.uk).  Such 
personal data may be disclosed to other UK Government Departments and public authorities. 

 
 
 
 
 
 
 
 
 
 2. 

External Engagement 

We work closely with foreign governments, partners in the travel industry and others to 

reduce the risks to British people when they travel abroad. This year we enhanced our 

cooperation with the Royal Life Saving Society and worked with them on the water safety 

information appearing on their website during the summer holiday season. We will 

continue to work with ABTA and the travel industry and fully endorse efforts to make their 

customers aware of the risks they may face during travel. 

I hope this offers assurance of our commitment to helping prevent future deaths of the 

kind tragically suffered by Mrs Curran.  

Yours sincerely, 

Deputy Director, Head of Strategy and Network Department, Consular and Crisis 
Directorate. 

The Foreign, Commonwealth and Development Office holds and uses data for purposes notified to the Information Commissioner under the 
General Data Protection Regulation and Data Protection Act 2018 (which may be viewed at www.informationcommissioner.gov.uk).  Such 
personal data may be disclosed to other UK Government Departments and public authorities.

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