Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0426, written 1 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2023 |
|---|---|
| Reference | 2023-0426 |
| Deceased | Musa Konteh |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report Musa Sidique Konteh – died on 19 March 2023 THIS REPORT IS BEING SENT TO: 1. Consular Feedback Team Consular Directorate Foreign, Commonwealth & Development Office King Charles Street London SW1A 2AH 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 29 March 2023, an investigation was commenced into the death of MUSA SIDIQUE KONTEH, then aged 30 years. The investigation concluded at the end of an inquest, heard by me, on 1 November 2023. The conclusion of the inquest was accidental death, the medical cause of death being: 1a asphyxia 1b pulmonary oedema as a consequence of drowning. 4 CIRCUMSTANCES OF THE DEATH (1) Musa and his girlfriend were staying at a beach resort in Sierra Leone on 18/19 March 2023. (2) On Sunday 19 March 2023, Musa hired a jet ski from the resort. (3) Having gone out on the jet ski alone, Musa failed to return. (4) A local eyewitness is said to have seen Musa in the water, but believed him to be swimming at the time and thought nothing of it. (5) A local search on the afternoon of 19 March 2023, recovered the jet ski but did not find Musa. (6) On Wednesday 22 March 2023, Musa’s body was found in the water. (7) There was no evidence to suggest that Musa used alcohol prior to taking the jet ski out. 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 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:- (1) Little, if any, health and safety procedures were in place for those hiring jet skis. For example: no instructions on the use of the emergency engine cut-off were given; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks; and no lifejackets were supplied to people hiring jet skis. (2) The relevant Foreign, Commonwealth and Development Office travel advice, warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK. 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 27 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: (a) (b) (next of kin) (Mr Konteh’s partner at the time). 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 Ian Potter HM Assistant Coroner, Inner North London 1 November 2023
See every Prevention of Future Deaths report matching Ian Potter, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.