Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0099, written 21 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2023 |
|---|---|
| Reference | 2024-0099 |
| Deceased | Sarah Waller and Laura Pottinger |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Rt Hon Therese COFFEY MP, Secretary of State for the Environment. Food and Rural Affairs 2 3 Chief Executive of Environment Agency , Chair of Environment Agency 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 On 20 April 2023 I commenced an investigation into the death of two women aged 56 and 52. The investigation has not yet concluded and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH Both Deceased were found in the River Great Ouse at Kempston Mill, BEDFORD, on Sunday 16 April 2023 at around 10.50 hours. It appears that, at 10.00am that morning, they had rented out two canoes from KEMPSTON outdoor centre and had been due to return them at 11:00hrs. At the time of discovery, one of the Deceased was still caught in the circulating flow at the base of the weir along with two canoes and 2 life jackets. Although both Deceased were recovered from the water, they were prounced dead at the scene. The outdoor centre have indicated that both women had been renting canoes for them regularly for some years and had experience of the river. 5 CORONER’S CONCERNS I visited the scene yesterday which 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: (brief summary of matters of concern) Although there is a physical barrier to prevent access to the top of the weir, there is no similar barrier to prevent access to the bottom which appears just as hazardous in view of the re-circulating flow (or towback), particularly during time of high water levels. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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, Regulation 28 – Before Inquest Document Template Updated 30/07/2020 namely by June 16, 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 Inland Waterways ASSOCIATION who may find it useful or of interest. 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 Dated: 21/04/2023 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – Before Inquest Document Template Updated 30/07/2020
1 response 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.
Emma Whitting Senior Coroner for Bedfordshire and Luton Coroner Service The Court House Woburn Street Ampthill Bedfordshire MK45 2HX 1st June 2023 Dear Ms Whitting, Environment Agency Response to Regulation 28 Coroners (Investigations) Regulations 2013 Report dated 21st April 2023 following the fatality of Laura Pottinger and Sarah Waller at Kempston Weir, Bedford. On behalf of the Environment Agency, I would like to send our sincere condolences to the families of Sarah and Laura. Following your site visit to the location and the concern that you set out in your Regulation 28 Report, I have discussed this matter with . We address below the following Matter of Concern that you have asked us to consider - “Although there is a physical barrier to prevent access to the top of the weir, there is no similar barrier to prevent access to the bottom which appears just as hazardous in view of the re-circulating flow (or towback), particularly during time of high water levels.” For all assets that we own, operate, maintain and control, we undertake a continual programme of public safety risk assessment (“PSRA”) in accordance with our duties under the Health and Safety at Work, etc. Act 1974 and The Management of Health and Safety at Work Regulations 1999. Following all significant events, environmental changes or otherwise every five years, we further review our PSRA for the asset/site in question. As a result of the review for this site, whilst the facts of the incident are being established we are taking the following actions; 1. Installation of a boom downstream of the weir on a temporary basis whilst a review of all the options for the site (including the removal of the weir) is undertaken. The weir serves no operational purpose to the delivery of the Environment Agency’s functions. It is a legacy asset, inherited from a predecessor body. Environment Agency Horizon House, Deanery Road, Bristol, BS1 5AH www.gov.uk/environment-agency 2. 3. 4. Installation of grab lines and throw lines on the downstream banks of the watercourse adjoining the weir, to aid rescue and exit from the watercourse. The timeframe to install the boom and grab/throw lines is dependent on the practical issues set out below (liaison with the landowner, and geology of the fixing points) but we are endeavouring to progress this as quickly as possible. Continue working with partner organisations for the delivery of a national water safety communication campaign, which aims to educate and increase public awareness of the hazards associated with the recreational use of watercourses, including structures within the channel and river control assets. Continued liaison with our partner organisations and stakeholders (including membership of The National Water Safety Forum and The Royal Society for the Prevention of Accidents) in respect of the best practice for the management of weirs. In determining these measures the following factors have been considered. 1. 2. The extent to which installing a downstream boom will act as an effective risk control measure. It will not be a physical barrier to prevent access. In general booms of this nature are installed upstream of a hazard to provide a point of rescue for individuals and/or craft who are being pulled by the flow of the watercourse towards the hazard. It provides a point of anchor against the flow and to enable movement towards the side of the channel. In the case of a downstream boom, the flow of the watercourse will pull individuals/craft away from the hazard. Only deliberate, purposeful movement against the flow would place individuals within the vicinity of the hazard. A boom will not provide an impenetrable barrier and so it will be relatively easy for individuals to circumnavigate it if they choose to. A boom will however provide a visual barrier which may provide river users with an additional indication that it is not safe to travel further. 3. Whether the installation of a downstream boom will create or increase any operational risk to Environment Agency employees or contractors which cannot be managed. Once in situ the boom will require inspection, management and maintenance to ensure that is operates effectively and doesn’t in itself become a hazard. 4. Whether the installation of a downstream boom will create or increase flood risk, due to debris becoming caught in it. 5. Whether the installation of a downstream boom will create a congregation point for 6. 7. 8. those who seek more challenging environments for water-sports activities. The boom will need to be securely anchored into the banks of the watercourse to ensure that it is safe and effective. The exact location where the boom can be situated needs to be determined having considered the structural integrity of the bank structures already in situ (revetments) and the identification of land with the required geology. The Environment Agency is landowner only of Kempston Weir itself and a small area of land in the immediate vicinity (please see attached plan). It is likely that a downstream boom will need to be situated in the land surrounding the weir, which is owned by a third party. Liaison and potentially the consent of the landowner will be required. There is no statutory right to navigate the waters leading up to and surrounding Kempston Weir. The statutory navigation begins downstream at Kempston Mill. The Environment Agency are the Navigation Authority for the statutory navigation. Use of Environment Agency Horizon House, Deanery Road, Bristol, BS1 5AH www.gov.uk/environment-agency 9. and presence in the watercourse outside of the statutory navigation is a private property matter concerning the owners of the land which forms the bed of the watercourse. Having considered the wider circumstances regarding this site, we are aware that there are canoe/kayak/paddleboard hire centres in the nearby vicinity. There is also a free carpark and known craft launch points with free access in the immediate locality. Anecdotally we have been informed that one of the centres uses the weir for supervised white-water training. The Environment Agency has limited powers to physically exert any control over these activities and this is even more so the case outside of the statutory navigation and on land not within our ownership which approaches the weir. 10. The Environment Agency has a statutory duty (to such extent as we consider desirable), generally to promote the use of inland waters and land for recreational purposes. To this end, where appropriate we work with a wide group of partner organisations to maximise the benefits that accessing the water brings to many individuals, whilst managing the risks arising from these activities. With our partner organisations, in addition to physical control measures, we strive to warn water users about the hazards arising from accessing the water and the assets within our control. We hope that this information addresses the concern that you have raised. Please let us know if there is anything further that you require to facilitate your investigation into this tragic incident. Yours sincerely Chief Executive Environment Agency Environment Agency Horizon House, Deanery Road, Bristol, BS1 5AH www.gov.uk/environment-agency
See every Prevention of Future Deaths report matching Emma Whitting, 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.