Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0501, written 18 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2024 |
|---|---|
| Reference | 2024-0501 |
| Deceased | Peter Jeffery |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Sedgemoor District Council
Bridgwater House
King Square
Bridgwater
Somerset
TA6 3AR
1
CORONER
I am Samantha Marsh, Senior Coroner, for the coroner area of Somerset
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 the 13th November 2023 I commenced an investigation into the death of Peter Ivor
Jeffery. The investigation concluded at the end of the inquest on the 10th September
2024. The conclusion of the inquest was death by Misadventure.
The medical cause of death was:
Ia) Drowning.
I record that “Peter Ivor Jeffery, aged 68, jumped into the water by the jetty at
Burnham on Sea beach around 3.30pm on the afternoon of Sunday 29th October
2023 to assist a stranger and her dog who were in distress in the water. He was fully
clothed in jeans, trainers and a snug boiler suit, which negatively impacted on his
ability to swim. Peter got caught in a riptide and was unable to be rescued by those
on the beach. This section of water is known to be particularly treacherous. Peter’s
body was discovered near to Stert Island on the 12th November 2023.”
4
CIRCUMSTANCES OF THE DEATH
Peter Ivor Jeffery (“Peter”) was a relatively strong, fit and healthy 68 year old man. On
the afternoon of the 29th October 2023, Peter went to the jetty at Burnham-on-Sea,
somewhere that he’d been to previously and was reasonably familiar with, having
been there before at different times and so he had experienced that part of the coast
in different weather and seasonal conditions; although he had never been in the
water, only observing the tide from the shore, which was something that he liked to
do.
1
Whilst at the jetty on this occasion, Peter noticed a woman (a complete stranger to
him) and her dog who were in difficulty in the water; the dog had entered the water
and got into difficulty and so its owner had gone in after it, also finding herself in
difficulty. The lady had never been to this location before and was not familiar with it
as she resides in another part of the country.
Peter, without hesitation, jumped into the water to try and help but was immediately
overcome by the water. He went under. There were differing witness account as to
whether or not he resurfaced shortly after entering the water but, if he did, it was not
more than once.
An off-duty emergency service personnel and the specialist rescue service personnel
(who by coincidence were at the scene) both declined to enter the water without
appropriate safety measures as they were aware of the dangers posed by the current
and tip tides in this area and were aware that they would have been putting their own
lives at risk by doing so.
The specialist rescue personnel gave evidence from his eighteen years of experience
of this part of the coastline that the tide/under-current can sweep a grown man away
in seconds as the water has the power to drag them under and there is no time to do
anything about it, it doesn’t matter how strong an individual is or how competent they
are in the water.
Peter was not seen again and a coastal search was coordinated to try and locate his
body. He was eventually located some two weeks later near to Stert Island.
I admitted pictorial evidence showing the signage that is currently displayed on the
walls and railings at the entrance to the Jetty. These showed or conveyed the
following messages:
(i)
(ii)
(iii)
(iv)
A warning about the potential risk posed by the sinking sand;
A warning not to park a vehicle on the jetty;
A warning that the gates to the jetty may be closed during high tide;
Signs displaying varying warning triangles; this does include warnings
about the
mud, sinking sand and risks posed by the tide.
Evidence was admitted by the rescue personnel that this area of water is known to be
notorious amongst locals.
I heard that signage and/or flags are displayed at the beach to advise against
swimming in certain stretches of that part of the coast, but that these are only
displayed in peak/summer season, and this incident happened out of season and so
no flags or additional signage was in place.
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. –
Whilst there are multiple signs in existence at the location, not all of these are for
public safety, some focus on more ‘administrative’ matters such as the closure of
gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly
important in the smooth administration of the public space, the consequences of such
are not life threatening and the size and prominence of such administrative signs and
2
surprising when compared with the signage that conveys potentially life-saving
information.
I am concerned that the risks posed by entering the water (which appear equal to, if
not greater than, the risks posed by the mud and sand) are not prominently and
clearly displayed to those who lack local knowledge, especially out of ‘season’. This
may cause people to misinterpret or underestimate the dangers posed by the
undercurrent and rip-tides which, of course, are under the surface of the water and so
not immediately obvious or visible.
As such people may continue to make ill-advised decisions to enter the water; water
which has the power and ability to overwhelm even the strongest of adult swimmers
within seconds.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe the
Council 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 14th November 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)
(ii)
(iii)
Mr Jeffery’s family
Burnham on Sea Lifeboat station
Burnham on Sea Search and Rescue (BARB)
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.
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
19th September 2024
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.
Somerset Council County Hall, Taunton Somerset, TA1 4DY Mrs Marsh Senior Coroner Somerset Coroners Service Old Municipal Buildings Corporation Street Taunton Somerset TA1 4AQ Please ask for: Email: Tel: Date: 11 November 2024 Dear Mrs Marsh, Report to Prevent Future Deaths case reference: 17900868 Thank you for your letter and investigative report (dated 19 th September 2024) into the sad death of Peter Ivor Jeffery, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. In providing this response to the Report, we offer our sincere condolences to Mr Jeffery’s family. Action to Address Concerns Raised On behalf of Somerset Council, I now want to outline our response to the Regulation 28 Report to Prevent Future Deaths concerning the death of Mr Jeffery (“the Report”), which identified matters of concern and recommended that action be taken to prevent future deaths. The matters of concern identified by the Coroner are outlined below: “Whilst there are multiple signs in existence at the location, not all of these are for public safety, some focus on more ‘administrative’ matters such as the closure of gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly important in the smooth administration of the public space, the consequences of such are not life threatening and the size and prominence of such administrative signs and surprising when compared with the signage that conveys potentially life-saving information. I am concerned that the risks posed by entering the water (which appear equal to, if not greater than, the risks posed by the mud and sand) are not prominently and clearly displayed to those who lack local knowledge, especially out of ‘season’. This may cause people to misinterpret or underestimate the dangers posed by the undercurrent and rip- tides which, of course, are under the surface of the water and so not immediately obvious or visible. As such people may continue to make ill-advised decisions to enter the water; water which has the power and ability to overwhelm even the strongest of adult swimmers within seconds.” Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty. In addition, line painting is being completed on the lower part of the jetty advising against access stating “Dangerous Currents no Access” I have attached below a copy of the signage to be installed at the entrance to the jetty. The work has been ordered and the signs and line painting are due to be installed on or before the 30th November 2024. Once the signage and line painting have been completed a further update will be issued to the Coroner with photographs of the signage in place. If you have any questions, please do not hesitate to contact me. Yours sincerely Head of Regulatory Services
Somerset Council County Hall, Taunton Somerset, TA1 4DY Mrs Marsh Senior Coroner Somerset Coroners Service Old Municipal Buildings Corporation Street Taunton Somerset TA1 4AQ Please ask for: Email: Tel: Date: 20 March 2025 Dear Mrs Marsh, Report to Prevent Future Deaths case reference: 17900868 I refer to my letter dated the 11 November 2024. As discussed in my letter of the 11 November 2024 I have attached below details of the signage installed at the Jetty in Burnham on Sea. This work was completed in November 2024. This has involved signage being installed at the top of the jetty and line marked signage being applied to the tarmacked surface I have attached below photographs of the signage at the jetty. Please accept my apologies for not sending this information earlier I have had a period of illness towards the end of November 2024 and have only recently returned to work. If you have any questions, please do not hesitate to contact me. Yours sincerely Head of Regulatory Services
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