Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0357, written 3 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jul 2024 |
|---|---|
| Reference | 2024-0357 |
| Deceased | Andrew Story |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| 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 after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Greek authorities via FCDO. 1 CORONER I am Ms Jacqueline Devonish, Senior Coroner for the coroner area of Cheshire 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 05 January 2024 I commenced an investigation into the death of Andrew James STORY aged 56. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: Accident 4 CIRCUMSTANCES OF THE DEATH On 12 October 2023, 56 year old Andrew Story went for a swim in the sea in Rethymno whilst on holiday in Crete. He was only gone for a few minutes when a bystander was seen undertaking CPR on him, on the beach. A post mortem conducted in Greece offered a cause of death as drowning in sea water. A UK post mortem identified drowning but also left ventricular hypertrophy. Mr Story was taken away by ambulance but was sadly confirmed deceased thereafter. 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: 'It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season. This coincided with tourist season making the use of that beach and sea for swimming generally, and particularly unsafe in the absence of red warning markers, signs or flags 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 26, 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 I have also sent it to 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: 03/07/2024 Jacqueline DEVONISH Senior Coroner for Cheshire 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.
Subject: FW: [EXTERNAL] Missing Responses from Government Departments Sent: From: To: 05/11/2024, 08:18:48 Regulation28reports Good Morning, Thank you for your e-mail. I can confirm that this response is still outstanding. We received the following communication on the 30th July, but have had nothing since: “Thank you for your email enclosing the Senior Coroners Regulation 28 Report. I am sorry for the delay in responding. I confirm receipt of the report, and that this has been transmitted, via the Foreign, Commonwealth and Development Office (FCDO) Coroner Liaison Officer, to the British Consulate in Crete for onwards transmission to the relevant Greek authorities. Whilst I can confirm the transmission, the FCDO cannot guarantee the Greek authorities will respond to the coroner’s report by the 26th August 2024, if at all. Please let me know if you require anything further.” Best Wishes – Coroner’s Officer Cheshire Coroner's Court, Museum Street, Warrington, WA1 1JX Phone: 01606 36 5612 / 3892 | Email: Visit www.cheshire.police.uk | Follow @cheshirepolice on Twitter | Like Cheshire Police on Facebook From: Sent: 05 November 2024 08:14 To: Subject: FW: [EXTERNAL] Missing Responses from Government Departments FYI Could you please confirm this is still the case, or send the relevant responses before I contact them. If they have been granted an extension please do let me know. The deceased this applies to are: Andrew Story Cheshire Foreign, Commonwealth and Development Office Thank you for your assistance in this matter. Kind regards, Olivia Olivia Adshead Assistant Private Secretary to the Chief Coroner Judicial Office Royal Courts of Justice www.judiciary.uk This e-mail and any attachments is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail. Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when deciding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. Monitoring / blocking software may be used, and e-mail content may be read at any time. You have a responsibility to ensure laws are not broken when composing or forwarding e-mails and their contents.
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