Prevention of Future Deaths reports · 2023
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 report | 9 Oct 2023 |
|---|---|
| Reference | 2023-0378 |
| Deceased | Sandra Curran |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 1 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
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.
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
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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