Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0272, written 6 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2024 |
|---|---|
| Reference | 2024-0272 |
| Deceased | Iain Hughes |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Channel Swimming Pilot Federation c/o Keystone Law – Pilot of the “Anastasia” 2. 1 CORONER I am Mr Zafar Siddique, Senior Coroner for the Black Country. 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 https://www.legislation.gov.uk/uksi/2013/1629/part/7 3 INVESTIGATION and INQUEST On 27 July 2023, I commenced an investigation into the death of Mr Iain Hughes dob 7 July 1980 who died on the 4 July 2023. The investigation concluded at the end of the inquest on 8 February 2024. The inquest was heard before myself sitting without a Jury and my conclusion at inquest was one of Misadventure. The medical cause of Mr Hughes death was recorded as 1a) Consistent with Drowning 4 CIRCUMSTANCES OF THE DEATH 1. Mr Hughes planned to do a channel swim to raise money for several charities. As part of this preparation they were in touch with the Channel swimming and piloting Federation (CSPF) for guidance and to organise a pilot to escort him across the channel. The pilot was, boat. and the crew on the “Anastasia” 2. The initial plan was to do the swim on 4-5 June 2023, but this was postponed to 19 June. On the day of the swim they were met by observer, . They were given an informal briefing about the swim. and the CSPF described this briefing as fragmented. She said she didn’t recall any discussion of Iain’s safety checks, warning signs to look out for and when the swim would be aborted. 3. During the early parts of the swim he made good progress and was on target for a record swim. The family assisted by preparing his feeds every half an hour. His progress and key observations were recorded on a log by . 4. Later his pace started to slow down and dropped from 54 strokes per minute to 51. At approximately 11 hours and 35 minutes into the swim he became submerged in the water. 1 5. Despite attempts at rescue and further searches by the coastguard he wasn’t recovered. 6. The family and the crew then returned to Dover and statements were taken by the Police. 7. Mr Hughes was then subsequently found in Belgium waters in Oostende on the 4 July 2023. 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. During the course of the inquest, I heard evidence from the pilot, . He confirmed at around thirty minutes before Mr Hughes became submerged, that he was concerned about progress and that it was likely the swim would be aborted. 2. It is not clear how this was communicated to the family and no action was taken to abort the swim. 3. My concern is this this lack of clarity of who and when should make the decision to abort a swim can result in unnecessary delay and increase risk. 4. I am told by the CSPF they have clear guidance and protocols in place and have been provided with several documents to support this. There is always an element of risk by the very nature of the channel crossing challenge. However, given this incident and confusion about when a swim should be aborted you may wish to review the situation further and how this is communicated to all those involved. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 8 May 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: The family of Mr Iain Hughes. 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 other person who I believe may find it useful or of interest. 2 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. 9 6/03/24 Z Siddique Senior Coroner 3
2 responses 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.
Dear , I did request that my cctv unit or a copy of what the coroner viewed some time ago from the police, but nothing has been returned. Can you please advise the coroner. The Matters of Concern. 2/ Not clear on how this was communicated to abort the swim. There are 2 cameras which view the port side which picks up the swimmer in the water but it also covers the Cabin entrance, and the other picks up the swim ladder did the coroner view 35 minutes before the incident which would have been on his feed, he would have seen me coming up on deck and talking to Mrs Hughes and requesting that she removes her husband from the water and that he was showing signs of exhaustion, and the audio might pick up her response, and that I would give them 30 minutes and I would be getting him out. This warning is given to the crew and helpers that there swimmer will not make it across the channel and we will be getting them out, and its not so much of a shock when we do, plus it gives the time to prepare, they can get very angry and helps there mental state. At this time Mr Hughes was tired but swimming and in no danger of drowning at this point, the last time I saw him he was head and shoulders above the water line going towards the back of the boat to the swim ladder where as the observer stated he submerged like a scene from the movie titanic. I think this was more than just drowning, 2/3 meters down in a foetus position arms and legs tucked in by the time my son tried to reach him. Therefore I request that I can view what the coroner view, and that the court request the police to return my equipment or supplies me with a copy of the video please, so I can make sense of this tragedy. How stop this from happening again, stop swimming in the sea. I thank you in advance for your help in this matter. Kind regards
CS&PF Honorary Secretary I 5 Charter House 1-4 Camden Crescent Dover Kent CT161LE secretary@cspf.co.uk 2/5/24 CHANNEL SWIMMING & PILOTING FEDERATION To: Mr Zafar Siddique Senior Coroner for the Black Country Dear Mr Siddique, Death of Mr Iain Hughes Response to Coroner's Regulation 28 report I write on behalf of the CS&PF Committee, in response to your Regulation 28 Report to Prevent Future Deaths. You have reported to us that having heard the evidence at the inquest touching Mr Hughes' death, you have the following concerns: 1. During the course ofthe inquest, I heard evidence from the pilot, . He confirmed at around thirty minutes before Mr Hughes became submerged, that he was concerned about progress and that it was likely the swim would be aborted. 2. It is not clear how this was communicated to the family and no action was taken to abort the swim. 3. My concern is this this lack of clarity of who and when should make the decision to abort a swim can result in unnecessary delay and increase risk. 4. I am told by the CSPF they have clear guidance and protocols in place and have been provided with several documents to support this. There is always an element of risk by the very nature of the channel crossing challenge. However, given this incident and confusion about when a swim should be aborted you may wish to review the situation further and how this is communicated to all those involved. Your view is that there is a risk of future deaths unless action is taken. On behalfofthe CS&PF Committee I would like to confirm that the CS&PF has done (and intends to do) everything it can to endeavour to address your stated concerns. In producing om response below the CS&PF Committee has considered carefully the key touch-points it has with • prospective and actual swimmers, 'Nothing great is easy' • • the volunteer force of"observers" for the CS&PF (being passengers placed on board the escort-vessels to "observe" and record whether attempts successfully comply with the CS&PF swimming Rules or not), and the piloting businesses ( comprising pilots, their crews and vessels) which are recognised by the CS&PF for the purpose of carrying each swimmer, the swimmer's support team (and the appointed observer) on each attempt to swim English Channel under the "swimming rules" within the "CS&PF Rules" published on its website at cspf.co.uk/cs-and-pf-rules: ROLE OF THE CS&PF The CS&PF does not have any involvement in how a swim is conducted, other than (via an observer) noting whether it's rules have been followed. The CS&PF's swimming rules are in line with the rules for "orthodox" channel swimming that are approved by the British and French authorities and have been followed since the sport of English Channel swimming began in earnest during the early 20th century. They are based on extremely challenging requirements that no assistance is given to swimmers to combat the effects of cold water and fatigue (both physical and mental), such as the wearing of wet-suits or other items providing enhanced buoyancy, heat-retention, speed or endurance. The rules also include provisions as to where and how a swim should start and be considered complete, for example. The role ofthe CS&PF is primarily to manage the CS&PF swimming rules and their application across every swimming attempt registered with the CS&PF to cross the English Channel. CS&PF-appointed volunteer observers are placed on board escort-vessels in order to record and report to the CS&PF Committee on the swim parameters, to enable the Committee to adjudicate whether the swim-attempt successfully complies with the CS&PF swimming rules or not. Ancillary assistance is also provided by the CS&PF for each swim-application. This includes pre-registration of each swim with relevant authorities and liaising with the recognised pilots. The CS&PF Committee is made up of a group of volunteers, who invariably have extensive personal experience of Channel swims, whether as swimmers, pilots and other escort vessel crew, observers and swimmer-support teams etc. The CS&PF naturally makes clear to any person enquiring as to whether a crossing can be made under more relaxed swimming rules than are provided within the CS&PF swimming rules, for example allowing wetsuits to be worn, that this is not possible for any swim being conducted under the auspices of the CS&PF. The typical response to such enquiries is to advise that at least one other entity is authorised by relevant authorities to conduct crossings under different rules, whilst pointing out that any such crossing should not be confused with the sport of orthodox channel swimming. As a not-for-profit organisation, the CS&PF does not provide commercial services to swimmers. Fees charged are solely to cover the CS&PF's administrative and operational costs of carrying out its role. Prospective swimmers are free to engage one ofthe businesses charging commercial fees for services to provide support with training, CS&PF swimmer- 'Nothing great is easy' registration and administration requirements, and swimmer support-crew for the swim attempt itself. COMMUNICATION BY THE CS&PF WITH PROSPECTIVE SWIMMERS Our website provides the main touch-points which the CS&PF has with prospective swimmers wishing to understand the processing requirements for any swim-attempt under the CS&PF's swimming rules. They use the website to instigate and process applications to swim, by downloading and completing our official forms. We have considered whether we should add any guidance to our website or to the forms to explain who can make the decision to abort a swim and when. However, we decided that this would be inappropriate for swimmers, for the reasons described in the specific section on aborting a swim set out below. The forms already make clear that every applicant must carry out a meaningful and considered self-assessment process for both medical and training purposes. The forms include notices and guidance designed to highlight for swimmers the prevailing themes that: • this is an extreme endurance activity and can never be free of risk of injury or death • • it is the swimmer's sole responsibility to ensure that the he or she is fully informed and prepared for the risks and requirements entailed in the context of that swimmer's training, preparations for the swim-attempt and the swim itself, and the swimmer needs to carry out his or her own risk-assessments at every stage before and during a swim-attempt to try to responsibly identify and minimise risks, including the risk ofthe swimmer ceasing to communicate satisfactorily with, or to follow direction from, the swimmer's support team or the escort vessel-crew. We have also considered whether to add (to the Swim Application Guidance document accessible via the website) specific guidance to swimmers about selecting a support team who are well-placed in terms of knowledge and experience of the swimmer and of endurance swimming in order to assist the swimmer to make appropriate decisions. However, we felt that the website page entitled "Risks and Responsibilities" already addresses this. We take the view that it is critical not to interfere with the overriding understanding which the CS&PF gives to each swimmer (via the information and notices on the website and in the forms) that regardless of whatever support a swimmer decides (in his or her sole discretion) that they desire or need, this does not absolve the swimmer from assessing their own health and ability before and at every stage during a swim attempt, in order to ensure their continued safety. CS&PF RECOGNISED PILOTS Each piloting business recognised by the CS&PF is independent from the CS&PF. We have no control over the businesses and there is no financial relationship. Stringent maritime and other laws already apply to all escort vessel-crew and their vessels in the provision of in-board and out-board escort-services, including in relation to safety provision. So, although we have considered this, our view is that it would be inappropriate and potentially in conflict with such requirements for the CS&PF to purport to compel piloting businesses to follow our own particular directions in relation to a swimmer or a support team. 'Nothing great is easy' The CS&PF's only involvement with piloting services is in relation to recognition of a piloting business for the purposes of carrying out CS&PF authenticated swims, as referred to in the CS&PF Rules. Although it is not within the CS&PF' s control, we have suggested to the recognised piloting businesses that they should satisfy themselves as to the adequacy, clarity and accessibility (amongst other things) of: 1. swimmer and passenger safety-briefings at or prior to the start of each escort- excursion for a swim attempt, covering emergencies requiring attention to, or recovery of, a swimmer in difficulties, and 2. escort vessel-crew training for such emergencies. ROLE OF OBSERVERS Observers receive guidance as to their role through the receipt of the CS&PF Observer Handbook and (if newly volunteering) attendance at a training session, so that they understand as prevailing themes, that • the observer's role is to observe and report on each swim attempt's apparent compliance with the CS&PF swimming rules • during a swim the observer can advise the swimmer and support team of any contradiction to the CS&PF swimming rules that could cause the CS&PF committee to refuse to ratify the swim as successful · • observers do not themselves have authority to adjudicate whether a swim attempt is or isn't compliant, as that role is solely performed by the CS&PF Committee subsequent to the swim, after taking in to account all relevant information as well as the observer's report • the observer may engage with the escort vessel-crew at various times during the swim in order to share observations from the observer's report, as this is often of interest to the escort vessel-crew. The Committee have reviewed whether any pro-active steps can be introduced in to our observer-training to help support the primary message that swimmers are responsible for their decisions and for assessing their own ability to continue an ongoing swim attempt, or to abort it. However, it was felt that the training might confuse observers unless it continues solely to focus on the need to learn and interpret the CS&PF swimming rules, in order to be effectively able to observe and report on them. DECISION TO ABORT A SWIM As you are aware, the CS&PF have been greatly saddened by Mr Hughes' death and all ofus on the Committee have given careful thought to your concern that clarification is needed as to who should take the decision to abort a swim as between the CS&PF observer, the swimmer, the swimmer's support team and the escort vessel-crew. As well as each Committee member giving this individual thought we have discussed it at all of our Committee meetings since the death, as well as informally. 'Nothing great is easy' Our view is that given that the CS&PF has no control over the piloting operations, nor management of the swimmer and passengers on board the escort vessel (as explained) we have concluded that there is no other action we should or can take in relation to this. We state this having in mind that (to the knowledge of the CS&PF Committee) no situation has ever arisen where a swimmer, swimmer' s support team or pilot has requested clarification from the CS&PF about this, or suggested that there has been any doubt about the fact that the swimmer, the swimmer's support team and the pilot each have a separate right to abort the swim without needing to seek approval from the others. Our view is that this is the most sensible (and the safest) arrangement. Conversely, we are aware that disputes between a swimmer and pilot can arise when the decision to abort an attempt is taken by the pilot in circumstances where the swimmer or support team do not feel it was necessary. Although this is a different issue from the concern we're been asked to address here, we feel it's worth pointing out that our position is not dissimilar, in so far as the CS&PF still has no ability to intercede on behalf of the swimmer or pilot in the dispute, because it is a matter relating to the swim-management, and so is governed by the contract between the pilot and the swimmer. We on the Committee hope that you are reassured that we have given your concerns careful thought, and have taken action where we feel we can. Your sincer~ly / For and on behalf of the CS&PF Committee 'Nothing great is easy'
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