Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0370, written 11 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 | 11 Jul 2024 |
|---|---|
| Reference | 2024-0370 |
| Deceased | Peter Dolan |
| Coroner | Alexander Frodsham |
| 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: 1 Boat Safety Scheme 1 CORONER I am Alexander FRODSHAM, Assistant 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 09 April 2024 I commenced an investigation into the death of Peter Richard DOLAN aged 63. The investigation concluded at the end of the inquest on 09 July 2024. The conclusion of the inquest was that: Accident 4 CIRCUMSTANCES OF THE DEATH On 08/03/24 a fire took place on a canal boat on the Bridgewater Canal, Whitbarrow Road in Lymm. When the fire was extinguished a badly burnt body was recovered from inside the canal boat which was later identified as being Mr Dolan. Police attended and confirmed that there was no suspicious circumstances. Reason for inquest - unnatural death. 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) Peter Dolan lived on a narrowboat which caught fire during the early hours of 8th March 2024. An investigation by Cheshire Fire and Rescue Service revealed that the likely ignition source was hot embers ejected from a solid fuel stove, and that there was no evidence of any smoke alarm having been fitted within the boat. The position of Peter's body indicated that he was lying on a sofa when he died. It is presently a legal requirement of BSS that boats be fitted with carbon monoxide alarms, but there is no requirement that boats be fitted with smoke alarms (unless it is a hire boat for overnight accommodation). Any equivalent requirement for all other boats may reduce the likelihood of further fatalities arising from smoke inhalation and/or burns. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 September 04, 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 , Cheshire Fire & Rescue Service 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: 11/07/2024 Alexander FRODSHAM Assistant 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.
Dear Chris I refer to the Coroner’s Concerns as set out in Regulation 28 Report concerning the tragic death of Peter Richard Dolan aboard a narrowboat at Lymm Cheshire in March 2024. The Coroner’s Concern is that, recognising that hire boats must have at least one smoke alarm, a legal requirement of BSS that privately owned boats be fitted with smoke alarms may reduce the likelihood of further fatalities arising from smoke inhalation and/or burns. The di(cid:431)erence is that Boat Safety Standards exist to support the duties of care of the navigation authorities and in regard to boats in private ownership and use, those duties are to ‘third parties, i.e. people and property beyond the confines of the boat such as other visitors to the waterways, neighbours of the waterways, and the sta(cid:431) and volunteers working on our waterways. Ultimately, on private boats, it is the boat owner who bears the responsibility for the safety of those aboard. Conversely, following the principles of the Visitor Safety Group and National Water Safety Forum, people aboard a boat let out for hire fall within that third-party category and thus hired craft must meet several higher standards, including having suitable working smoke alarms. Currently the BSS continues to promote our strongest recommendation to private boat owners to fit smoke alarms since the time we successfully lobbied the alarm industry to include certification standards appropriate for marine use. Our promotion of smoke alarms with the support of UK fire and rescue services and others has had some success, according to our most recent filed survey, around half of private boat owners enjoy the protection of a working smoke alarm on their boats. Notwithstanding all of the above, and more aligned to your recommendation, the BSS is committed to a public consultation by the end of this year on the commendation to research if evidence exists to introduce a mandatory requirement for all boats on waterways participating in the BSS, to be fitted with a smoke alarm. The evidence we are tasked with seeking is to support the argument that working smoke alarms also provide protection to those aforementioned third-parties. Our di(cid:431)iculty in finalising the consultation document, is achieving su(cid:431)icient and supportable evidence of that protective mechanism. We can see the theoretical routes aimed at reducing the risk of boat fires spreading (one of our roles), but finding tangible examples to support the theories is di(cid:431)icult as Fire and Rescue Services are not routinely providing such information, albeit we have sought and had agreement from the National Fire Chiefs Council for the sharing of fire incident data. In case you harbour a question, the introduction of the mandatory BSS requirement for carbon monoxide alarms on boats in 2019 was grounded on evidence of carbon monoxide produced on one boat potentially entering adjacent boats and so third parties were at risk. All this stated, we still remain confident that we can present a supportable argument for increasing the regulation in this area and as soon as we have it collated and marshalled, I will inform you at the time the smoke alarm BSS public consultation is launched. Related to what I stated earlier about fire incident information, I would be grateful for a copy of the full report from the Coroner, in order that we may assess any wider safety lessons from the tragic circumstances and how actions and activities and may help prevent fires occurring which is our ultimate goal. Kind regards Communications Manager Boat Safety Scheme www.boatsafetyscheme.org T: @BSS_BoatSafety G+: Boat Safety Scheme Fb: BSS.BoatSafety Boat Safety Scheme c/o National Waterways Museum Ellesmere Port, South Pier Road, Ellesmere Port Cheshire CH65 4FW us W boatsafetyscheme.org/contact- The Boat Safety Scheme Limited is a not for profit company limited by guarantee registered in England and Wales with company number 15501423, registered office address c/o National Waterways Museum Ellesmere Port South Pier Road Ellesmere Port Cheshire CH65 4FW.
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