Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0243, written 2 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2024 |
|---|---|
| Reference | 2024-0243 |
| Deceased | Michael Dalkin |
| Coroner | Clare Bailey |
| Coroner area | Teesside and Hartlepool |
| Category | Alcohol, drug and medication 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 after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 CORONER I am Clare Bailey HM Senior Coroner for Teesside & Hartlepool Coroner’s 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 and INQUEST On 18 February 2020 I commenced an investigation into the death of Michael Lee DALKIN aged 22. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was that: Michael Lee DALKIN Suffered with hypoplastic left heart syndrome. On the evening of 26/12/2019, he was socialising in Stockton town centre. He consumed alcohol and illicit substances. In the early hours of 27/12/2019, he was inside Goldie’s Bar. Two off duty door supervisors believed he was going to cause injuries with a glass. One of the off duty door supervisors removed the glass from him and moved him to the floor. They transported him outside the bar by carrying him by his limbs. They placed him on the floor outside the bar. Their actions were inconsistent with SIA training but reasonable and proportionate in the circumstances. Michael Lee DALKIN died in an Ambulance on Stockton High Street on 27/12/2019 due to a combination of his congenital heart defect, ingestion of alcohol and drugs and stress caused by the interaction with the off duty door supervisors. 4 CIRCUMSTANCES OF THE DEATH Mr Dalkin was socialising in Goldies bar, Stockton High Street in the late hours of 26.12.19 and early hours of 27.12.19. Two off-duty door supervisors were in the venue. They observed Mr Dalkin in a group of people who were arguing between themselves. They saw him walk to the bar and pick up an empty glass. Mr Dalkin placed the empty glass behind his back and started to walk back to the group with whom he had been arguing. Both off-duty door supervisors formed the impression that he was going to use the glass as a weapon. One of the men removed the glass from him. Mr Dalkin threatened the man with injury, so he was moved to the floor and escorted out of the premises. Outside of the venue Mr Dalkin collapsed and was attended to by the emergency services. He died in the ambulance. Evidence was given at the Inquest about the door supervisors employed and in used at Goldies bar on 26/27 December 2019. Evidence was given by the owner and designated premises supervisor as to improvements made however his evidence lacked credibility. Evidence was provided by other witnesses who were former door supervisors at Goldies and Che Bar (adjacent bars both owned by ). I determined that on 26/27 December 2019 the door supervisors were made up of one SIA registered door supervisor who was acting as a door supervisor, an unlicensed door supervisor acting as a door supervisor, the SIA registered designated premises supervisor who said he left the premises at approx. 21:00 on 26.12.19 and another man who was SIA registered but carried out the role of the manager and did not act as a door supervisor. Regulation 28 – After Inquest Document Template Updated 30/07/2021 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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) 1. The use on an unlicensed door supervisor. 2. The use of the SIA registered designated premises supervisor as a part �me door supervisor. 3. The use of an SIA registered manager who was not carrying out the role of a door supervisor but was held out to be a door supervisor. 4. Comple�on of SIA registers with informa�on that did not reflect the real number of opera�onal and effec�ve door supervisors 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, namely by June 27, 2024. 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 , SIA, Cleveland Police Licensing who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 2 May 2024 Clare Bailey HM Senior Coroner for Teesside & Hartlepool Coroner’s Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS In response to your above report I would comment as follows. My business premises, “Goldies Bar”, 93 High Street, Stockton on Tees is licensed to provide alcohol and regulated entertainment under the provisions of The Licensing Act 2003 by Stockton on Tees Borough Council and as such is subject to mandatory and voluntary conditions to ensure compliance with the four statutory licensing objectives namely: 1. The prevention of crime and disorder 2. Public safety 3. The prevention of public nuisance 4. The protection of children from harm I have enclosed a copy of my licence which outlines the range of conditions attached to the licence which I have a statutory obligation to comply with. As a licensed premise I am subject to regular compliance inspections by the responsible authorities, including the police and local authority licensing officers and when areas of concern or non compliance are identified I can be subject to prosecution and/or a review of my premise licence by the Council which in turn could result in the suspension, amendment or revocation of my licence and ultimately the loss of my business. Following the sad death of Mr Dalkin a formal review of my premises licence was brought by Cleveland Police with representations from local authority licensing and public health officers. This formal review was heard by the Licensing Sub Committee of the Council’s Statutory Licensing Committee on 8th June 2020. At that hearing the Committee could have determined that I was unfit to continue as the designated premise supervisor, but they did not. They could have also determined to revoke my premise licence, but once again they did not. Instead they heard that I had entered into extensive constructive negotiations with all parties to the review to discuss whether the issues which were at the root cause of the review application could be addressed by agreement being reached on amendments to the premise licence including additional conditions. At that hearing the Committee were told that I had acknowledged that changes needed to be made and I gave assurances to the Committee that I would introduce and maintain improvements at the premises. The Committee determined therefore that the review could be dealt with in the manner suggested by the parties and that was a proportionate solution to the review so they resolved to amend my premise licence as follows: 1. A reduction in hours for the supply of alcohol to 02:30 2. Maintaining an incident book 3. The provision of an external customer management policy 4. A minimum price for the sale of alcohol 5. The use of an external security agency to provide registered door supervisors and which is on the ‘Approved Contractors List’ 6. Minimum numbers of door supervisors to be employed stipulated 7. A condition that I cannot be included towards the minimum number of door staff 8. Door staff signed in at Che Bar cannot also be signed in at Goldies Bar at the same time Therefore with particular reference to your four matters of concern I would make the following points: Point 1. This is both illegal under the provisions of the Licensing Act 2003 and is subject to a mandatory condition on my licence that any person carrying out security activity must be licensed by the Security Industry Authority. Point 2. This is now prohibited by a condition on my licence. Point 3. and Point 4. The minimum number of door supervisors to be provided is now stipulated as a condition on my licence and a further condition prohibits door supervisors signed in at Che Bar also being signed in and used in Goldies Bar. Since the review hearing my premises have been subject to compliance inspections by Cleveland Police when no further issues have been identified and they are satisfied with how the premises are being managed. In conclusion I would reiterate that as a premise licence holder under the provisions of the Licensing Act 2003 I have a statutory obligation to ensure compliance with the conditions on my licence and any further concerns or non compliance found could result in my prosecution and/or ultimately the revocation of my licence and the loss of my business. I trust this information confirms to you that action has been taken to address your concerns and that these changes are regularly monitored for compliance by the regulatory authorities. Yours Sincerely,
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