Christopher Kapessa

correspondence address: 

POBox171S7
Birmingham B2 2XS

Exeter office 
Groundftoor 
Keble House 
Southemhay Gardens 
Exeter EXI INT 

+44 (0)370 ZTO 6000 
brownejacobson.com 

: 

Browne 

Jacobson 

The Coroner's Office 
The Old Courthouse 
Pontypridd 
CF271JW 

By email 

17 April 2024 

Dear Sir 

Inquest Into the death of Christopher Kapessa 

This is The Coal Authority's (the  CA) response to HMAC Regan's Report to Prevent Future 

Deaths  dated  24  January  2024,  and  made  under  Regulation  28  of  the  Coroners 

(Investigations) Regulations 2013. 

The report  arose from  an inquest  held  between 8  and  22 January 2024  into  the death  of 

Christopher Grace Kapessa, who died when he was pushed into the River Cynon which runs 

through land owned by the CA. 

We would  like to take this opportunity to restate our condolences to Christopher Kapessa's 

family and acknowledge the tragic nature of this case. We would also like to thank the Coroner 

for his report. 

The Report to Prevent Future Deaths covers five matters of concern to the Coroner and this 

response is structured accordingly. Those matters are: 

(1) The Coal Authority was aware that members ofthe public used the site for purposes 

including recreational walking.  The Court found that the site was known by children as 
a  site  from  which  to  swim,  but  that  this  was  unknown  to  the  Coal  Authority. 

Nevertheless,  Coal  Authority  documentation  was  not  easily  cross  referenced  or 

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 accessible to Inspectors to ensure that any reports that might be made with respect to 

activities by members of the public who might put themselves at risk were available to 

inspectors when conducting safety inspections. 

We acknowledge the evidence was that some children knew of the area as a place to swim 

and this was not known to the Coal Authority. 

At paragraph 74 of the Coroner's judgement he states as follows, 

"I accept the evidence of

 that searches for the location of the site within the 

authority's database would  have been able to be  cross referenced  and  would  have 

identified any reports made to the authority that children  or others had used the site 

for swimming, and that there was in fact no such awareness" 

At the time of the incident there  existed and  had  existed for many years,  a  24-hour hazard 

report line which enabled such reports to be received, logged and acted upon and there is no 

evidence, as became clear during the inquest, that such reports were received by the CA.  In 

addition to this any observations made by CA staff (outside of formal inspections) or reported 

by the public through other channels are recorded through the CA's online Health and Safety 

portal. 

The CA has enhanced its documentation to make  clear that Project Managers undertaking 

the  site  inspection will  undertake a  pre inspection review which will include interrogation  of 

previous  risk  assessments  and  interrogation  of  CA  systems  to  check  whether  relevant 

previous observations have been made by CA staff or reported to the CA by other third parties. 

Extracts from  the  Coal  Authority's  procedures:  The  Property  Site  Inspection  Process flow 

chart, and the CA's Risk Assessment Guidance notes are attached for reference. 

The CA is, therefore, satisfied that any reports or information provided by an employee or any 

third-party  raising  safety  concerns  regarding  its  sites  will  be  actioned  and  recorded  as 

appropriate and made available to the site's responsible inspector. 

(2) No specific water safety policy relating to risk assessment or the provision ofsafety 

equipment was in place, or Is cu"ently In place. 

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 As  stated in the letter of the  17 January 2024, the CA was at that time developing a water 

safety procedure.  This sits alongside the CA's  procedure on safe working near water.  The 

CA's overarching health, safety and wellbeing policy, safe working near water procedure and 

new Water Safety Procedure are all attached for reference. 

In  developing the  Water Safety Procedure and control  measures identified within  it,  the CA 

have consulted the EA on their operational arrangements and reviewed current best practice 

guidance in the UK, which includes information about the provision of life saving equipment 

and  the  circumstances  when  it  might  best  be  used.  The  documents  listed  below  were 

considered when developing the Water Safety Procedure: 

-

Environment Agency Operational Instruction 733_ 11  Public safety risk assessment of 

assets in the water environment- recreation, water, and land access 

- UK Drowning Prevention Strategy 2016-2026 

- ROSPA Managing Safety at Inland Waterways 

- Visitor Safety Group Guidance Managing Visitor Safety in the Countryside 

- VSCG Managing Visitor Safety in the Historic Built Environment 

- DEFRA Guide to Public Safety on Flood and Coastal Risk Management Sites 

It is, of course, important that any such procedure provides guidance on assessing the viability 

of the provision of such equipment and does not simply create a blanket policy requiring the 

same. 

The Coroner will recall during the evidence of

, that extracts from "Mark Allen's Law: 

Water safety and drowning prevention", a document created by the Welsh Government, were 

put to him,  and sections read, namely, 

"United Utilities developed a pilot scheme with Greater Manchester Fire and Rescue 

Service and some of the families that had lost loved ones in drowning. This involved 

creating an information board with throw-lines,  and of them were installed 20 across 

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 eight sites. 

However,  since  the  throw-lines  were  installed  none  have  been  used  but  their 

maintenance  has  proved  to  be  a  'massive  challenge'  with  all  of them  vandalised 

including damage to the boards, the boxes broken and throw-lines stolen. Regrettably 

this has happened regularly." 

And, 

"NRW conducts  Public Safety Risk  Assessments on  its reservoirs  and flood  assets 

and  applies  control  measures,  such  as  signage,  fencing  and  barriers  to  exclude 

members of the public. However, they caution that whilst the provision of throw-lines 

might seem attractive and can at times be a sensible step there are very real difficulties 

that need  to  be  considered.  Their provision  might be seen to condone entry to the 

water and  encourage  unauthorised  access.  Perceptions  of personal  risk  might  be 

lowered if public rescue equipment is provided. NRW experience vandalism and theft 

where  they do  provide  public  rescue  equipment  of this  nature  at visitor sites.  It is 

expensive to adequately inspect and maintain to ensure it will always be available and 

in serviceable condition." 

The concern over having a blanket policy of provision of equipment was also addressed in a 

response by

 in his evidence, where he stated, 

"From  experience  on  other  sites  generally  life-saving  equipment  is  abused  or 

vandalized or made inoperable quite frequently" 

Thus the Coal Authority's procedure states that: 

Some people may regard the presence of rescue  equipment as tacit approval to enter the 

water.  Moreover,  in  public  places,  such  equipment is  often  subject to  vandalism  or theft, 

rendering it ineffective.  There  are  also  limitations  about  the  effectiveness  of water rescue 

equipment in many situations including the competence of the person using it and the effect 

of water shock,  which may render the individual being rescued unable to utilise it.  For these 
reasons,  it will rarely be appropriate to install them in places to which the public have access. 

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 (3)  The annual Inspections  conducted by the Coal Authority were  limited In content, 

unclear In format and Identified no clear criteria to  be used for the basis of decision 

making. 

As  outlined  in 

  letter  of the  17th  January,  a  new  Public  Safety  Risk 

Assessment (PSRA)  process was introduced  during July 2020.  The  PSRA,  its associated 

guidance and  the a-learning  package,  was  developed  by the  Authority's  Safety,  Health  & 

Environment (SHE) team in collaboration with the Environment Agency and with good practice 

adapted to meet the specific needs of the Authority. 

The PSRA provides an improved structure for classifying  sites,  ensuring that site visits are 

prioritised  based  on  a  proportionate 

risk  assessment  process  and  subsequent 

recommendations for action are proportionate and completed in a timely manner. 

To  support the  implementation  of this  process,  those  involved  in  the  implementation  and 

management of the scheme were required to complete a  PSRA e-learning package, and to 

demonstrate competence before using the new toolkit in the field.  New starters to the team 

have been trained to ensure they are competent to use the system. 

The  CA  is  currently  re-running  the  PSRA  a-learning  training  for  all  inspectors  ahead  of 

commencement of the 2024-25 inspection  programme.  Further face to face workshops for 

inspectors are planned for the first quarter of 2024-25 to reinforce good practice and explore 

any opportunity that may be available to further improve the process. 

(4)  Inspectors  were not provided with  any guidance as  to  how to  assess  whether 

members of the public accessing the site should be safeguarded from the risks ofdeep 

and fast flowing water, and If so how.  No slgnage was In place to warn of the specific 

dangers  of deep  and fast flowing  water.  No  consideration was  given as  to  whether 

equipment to  assist in  the rescue of members  of the public  who  may have got into 

difficulty, such as throw lines, should be provided. 

This has been  addressed through the Water Safety Procedure which provides guidance on 

all 

these  aspects  e.g.  circumstances  when 

information/signage/fencing/water  rescue 

equipment should be used to safeguard members of the public. 

s 

 (5)  Remedial  work  was  Identified  to  remedy  aspects  of the  site  which  rendered  It 

unsafe, but were not ca"led out. No system appeared to be In place to ensure that such 

works were carried out following inspection. 

This  concern  has  been  addressed  through  the  reviewed  Public  Safety  Risk  Assessment 

process as mentioned above and in Paul Frammingham's letter of the 17 January 2024 where 

in addition to a description of the new Public Safety Risk Assessment process, he states, 

"Follow  up of actions  arising  from  the  inspection  of non-operational  sites  has been 

enhanced, by incorporation into a single system for the whole of the Authority's public 

safety operation,  with  clear  action-tracking,  management  reporting  and  review.  All 

remedial works identified by the Authority, or notified to the Authority, are followed up 

effectively." 

There is now a  system in place and a process to  be followed which ensures that identified 

works are recorded,  notified,  remedied  and  reviewed,  with  Project Managers (who inspect 

sites) now having the authority to organise immediate repairs up to the value of £25,000 on 

their own  initiative.  The  latter reduces  the  possibility  that lower cost  repairs,  which  would 

include  additional  fencing  for example, can  be undertaken  more swiftly than  if  it had  to go 

through the budget process and would remain in the immediate oversight of the inspector. 

Yours faithfully 

-±,r~~o~  LLP 
Browne Jacobson LLP 

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