Andrew Rees

Ms Myfanwy Buckeridge,  
Assistant Coroner for the Area of Avon 
The Coroner's Court,  
Old Weston Road,  
Flax Bourton,  
BS48 1UL 

27.2.2024 

Record of Inquest Andrew James Rees & Regulation 28 Report to prevent future deaths. 

Dear Madam 

Further to your Regulation 28 Report following the inquest into the death of Andrew James Rees, I 
write on behalf of Boatfolk Marinas Ltd, to advise you of the actions we have taken. 

We have increased the frequency of our visual inspection of the chains from monthly to weekly 
and have added a further physical 'pull' test that will take place on each chain on a monthly basis. 
As with all our inspections, both inspections will be recorded on our inspection management 
system. 

 Yours faithfully, 

Marina Manager 
Portishead Marina

Clyde & Co Claims LLP, 2 New Bailey Square, Stanley Street, Salford M3 5GS 
T +44  0117 933 7700 F +44  0117 933 7777  DX 14302 MANCHESTER 1 clydeco.com 

Deputy Coroner for the District of Avon Coroner's Court 
The Courthouse 
Old Weston Road 
Flax Bourton 
Bristol 
BS48 1UL 

Client Confidential 

7 March 2024 

Dear Madam 

Inquest Andrew James Rees 

We are now in receipt of your Regulation 28 report pursuant to paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and dated 9 
January 2024. 

We are required to respond to your report by 11 March 2024 and it is noted that our response must contain 
details of action taken or proposed to be taken, setting out the timetable for action.  Alternatively, if no action 
is proposed then an explanation should be given in this regard. 

This letter is the response of North Somerset Council only in respect of your report. 

According to the Regulation 28 report your concern in respect of North Somerset Council is as follows: 

‘During the course of evidence one of the triggers to generate a review of the Port Marine, Portishead Risk 
Assessment by North Somerset Council was stated to be a significant change of use but no formal assessment or 
measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken 
place was apparent.’ 

Following the inquest on 9 January 2024 we wrote to you on 12 January 2024 seeking clarification of the brief 
indication you had given at the conclusion of the inquest that you would be making a regulation 28 report.  
We raised a number of matters within that letter which have not been responded to and unfortunately the 
report was made, it seems, on the day of the inquest and immediately after it. 

The trigger for the duty to make a regulation 28 report is that a concern is revealed by the evidence from the 
whole of the investigation (not just the inquest hearing itself) that circumstances creating a risk of further 
deaths ‘will’ occur, or ‘will continue’ to exist in the future.  There must be a concern of a risk to life by present 
or future circumstances and the action that the Coroner opines should be taken must be to prevent those 
circumstances ‘happening again’ or reduce the risk of death arising from those circumstances. 

Your inquest heard extensive evidence from 
 from the Council.  In light of 
this evidence and the extensive documentation supporting it, we do not believe that there was any evidence 
to support the contention that, ‘no formal assessment or measure of whether a change of use (e.g. increase in 
amount or type of footfall/increased cyclists etc.) had taken place was apparent.’  Further, we do not believe 

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 that there is any evidence that this matter constitutes circumstances creating a risk that further deaths will 
occur or a risk will continue to exist in the future.  In our view, the evidence revealed the contrary as follows: 

There was considerable evidence about previous risk assessments, reviews and audits of the area 

1. 
between at least 2008 and 2023, with copies of the same provided to the court and explained, where 
necessary, in lengthy statements and oral evidence.  Those assessments had clearly taken into account present 
and proposed use of the area and demonstrated a formal measure of change of use. 

The oral evidence given by both 

2. 
use had historically been taken into account. 

 supported the position that change of 

The evidence before the court showed that in fact the locus was stable and had been for a number of 
3. 
years in respect of its use with a local school, leisure club, housing and use by cyclists long being the case (oral 
evidence of 

 in particular). 

Furthermore, 

 explained in his oral evidence that there had been a consideration of 
4. 
projected population previously and no change to the area since requiring a re-assessment of risk from a 
population perspective.  This had been well accounted for and taken into consideration. 

Before the court there was no evidence of any significant change of use to the area since the council 

5. 
took over responsibility for the west side of the Marina. Questions posed on behalf of the family about the 
potential change were not evidenced and in any event dealt with by 

, as set out above. 

In terms of the level of risk historically and indeed now, there has been one incident involving a child 

6. 
falling into the Marina in 2013 (which led to the Gallagher Basset report in 2013) and one suicide at an 
unknown area in around 2016 / 2017.  The incident in 2013 was in specific circumstances where a child was 
unsupervised and no death occurred.  Apart from these incidents there is absolutely no evidence before the 
court of any other accidents, incidents, deaths or near misses at this part of the Marina or indeed any part of it 
either historically or since Mr Rees’ tragic death. There is no evidence before the court or identified in the 
evidence provided to the interested persons that there is any risk to life in the area, on-going or otherwise and 
despite the proximity of the school, leisure centre and residential premises. 

Past risk assessments have been reviewed with any significant change of use or an incident being 

7. 
accounted for.  There is no evidence that this has not been a proper way to approach the assessment of risk in 
the area, particularly evidenced by the lack of issues with the area. 

The latest risk assessment which was put forward at the inquest hearing in evidence had a review date 

8. 
of February 2024.  This date was set to allow North Somerset Council to reflect on any aspects of the inquest 
evidence and taking into consideration that until disclosure of the inquest bundle took place, just days before 
the commencement of the inquest on 9 January 2024, North Somerset Council had no indication of the actual 
facts surrounding this incident.   In line with the written risk assessment and the evidence given at the inquest 
itself this risk assessment has been further reviewed and we attach a copy of it to this letter.  This shows that 
there will be an annual risk assessment and that risk assessment review will be triggered in a number of 
circumstances, including any change of use of the area. 

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Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 In all the circumstances, whilst we express our sincerest condolences to the family and friends of Andrew Rees, 
we have carefully considered the precise terms of the concern raised and on this occasion do not believe that 
there is either a risk that further death will occur or that North Somerset Council had not properly assessed 
risk in the area either historically or presently and beyond those changes already evidenced in detail at the 
inquest.  Notwithstanding the fact that we do not accept the threshold for the making of a Regulation 28 
report was reached, we have updated our risk assessment since the inquest and as indicated above in any 
event. 

Yours faithfully 

Clyde & Co Claims LLP 

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Client Confidential