Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0538, written 10 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2024 |
|---|---|
| Reference | 2024-0538 |
| Deceased | Sunnah Khan and Joseph Abbess |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Child Death (from 2015) · Other related deaths |
| Organisation named | South West Ambulance Service NHS Foundation Trust |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Secretary of State for Education 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 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 2nd June 2023, an investigation was commenced into the deaths of Sunnah Summayah Khan, born on the 11th January 2011 and Joseph Ian Abbess born on 22nd November 2005. The investigation concluded at the end of the Inquest on the 4th October 2024. The medical causes of death were: Ia Drowning The conclusion of both of the Inquests was accident 4 CIRCUMSTANCES OF THE DEATH On the 31st May 2023 both Sunnah, who was 12 years of age, and Joe, who was 17 years of age, travelled to Bournemouth to spend the day at Bournemouth East Beach. Sunnah had travelled with her family and Joe had travelled with his friends. Neither knew each other. At some point after 15.14 hours they, separately, entered the waters at the beach in the designated safer swim zone, where they remained. At approximately 15.45 hours an intense flash rip current occurred in the waters, and both became separated from those they were with in the water. At approximately 16.18 hours, Joe was seen in an unresponsive condition faced down in the water. He was recovered from the water straight away and despite attempts at resuscitation and a brief period of return of spontaneous circulation, his death was confirmed later that day. At approximately 16.45 hours, Sunnah was seen in an unresponsive condition faced down in the water at the shoreline. She was recovered from the water straight away and despite attempts at resuscitation, her death was confirmed later that day. 1 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 will 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 inquest evidence was heard that: i. As the Maritime and Coastguard Agency (the MCA) “Managing Beach Safety” document (found here) highlights, UK beaches are special places which attract millions of people every year to enjoy the beauty of the beach and create lifelong memories. Like every other body of water there is an element of risk and unpredictability which can lead to fatalities through drowning. ii. One of the ways to reduce fatalities through drowning is by warning and informing users the water of the potential dangers. iii. The National Water Safety Forum (NWSF) was formed in 2004 and is a UK-focused voluntary network working to reduce water- related deaths and associated harm. Members of the NWSF have undertaken a great deal of work to supplement the awareness of water safety. This includes, for example, work by the Royal National Lifeboat Institution (the RNLI), the MCA and the Royal Lifeguarding Safety Society (the RLSS) to name just a few organisations. Despite the great efforts by these agencies, unfortunately this information is only available to those who have access to it, whether that be through the internet, media campaigns or other resources. iv. Water safety is covered in the physical education part of the curriculum at primary schools in the UK and by the end of primary school all children should be able to swim at least 25 metres and have an understanding of self-rescue and survival skills to undertake the practical element of this learning. v. vi. Research, which was undertaken prior to the covid pandemic which began in March 2020, has shown that 1 in 4 children do not get access to this education. Further since the covid pandemic there has been a reduction in schools’ access to swimming pools. If children do not get access to this vital lifesaving education in school, there are concerns as to where this awareness will come from. Some will receive it from privately funded swimming lessons, however not every child is fortunate enough to have such lessons. vii. The RLSS and Sunnah and Joe’s mothers have been advocating for water safety to become part of the classroom part of the curriculum as opposed to the physical education part of the 2 curriculum on the basis that if children cannot do the practical part of water safety, they will at least have access to water safety awareness and lifesaving skills in a classroom setting. viii. Members of the NWSF, for example, volunteer members of the RNLI, the MCA do go into schools to provide talks to children, however, this would not be provided at every school. Further, the RLSS and Swim England provide resources that can be used in schools to educate children about the risks and survival skills around water safety. Again, this is delivered on a voluntary basis and will not be provided in every school. 2. I have concerns with regard to the following: i. ii. There are inherent dangers of using any form of water and it is crucial for people to have an awareness of these risks and how to manage them as the lack of awareness could lead to more deaths from drowning. An ideal opportunity to warn and inform all members of the public would be through educating children of the risks. The lack of providing education to children around these risks through the national classroom curriculum could lead to future deaths. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, 5th December 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: (1) Sunnah’s family (2) Joe’s family (3) Royal National Lifeboat Institution (4) Maritime and Coastguard Agency on behalf of His Majesty’s Coastguard (5) BCP Council (6) South West Ambulance Service NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. 3 I have also sent a copy of this report to the following persons for their awareness: a) The National Water Safety Forum b) The Royal Lifeguarding Saving Society 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 Signed Rachael C Griffin 10th October 2024 4
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.
Minister for School Standards Department for Education Sanctuary Buildings 20 Great Smith Street London SW1P 3BT 5 December 2024 Dear Rachel Griffin, The Secretary of State for Education has had the privilege of receiving and responding to correspondence from both Sunnah and Joe’s mothers and I also extend my heartfelt condolences to them and their families. Thank you for writing to , Secretary of State for Education, following the conclusion of the Inquest of the deaths of Sunnah Summayah Khan and Joseph Ian Abbess enclosing the prevention of future deaths report. The prevention of future deaths report sets out the importance of water safety awareness and you state that “An ideal opportunity to warn and inform all members of the public would be through educating children of the risks. The lack of providing education to children around these risks through the national classroom curriculum could lead to future deaths.” I agree that schools have a crucial role to play in helping ensure all children learn to swim and know how to keep themselves safe in and around water. This can be especially important for those pupils who may not have the opportunity to take part in swimming and water safety lessons outside of school. We have set up an independent Curriculum and Assessment Review which is seeking to deliver a curriculum that ensures children and young people leave compulsory education ready for life and ready for work, building the knowledge, skills and attributes young people need to thrive. In parallel we are carrying out further engagement on changes to be made to statutory Health Education. In making those changes, we will look at how best to complement swimming and water safety lessons already delivered through the PE curriculum, to ensure that all pupils are taught about water safety, including the water safety code, as recommended in the report. This consideration will build on the work and opportunities that are already underway. Data from Sport England Active Lives Children and Young People Survey (2022/23) report that 94.2% of primary schools surveyed reported they provide swimming lessons. As you have highlighted in your report, swimming and water safety are compulsory elements of the National Curriculum for Physical Education. It states that: All schools must provide swimming instruction either in key stage 1 or key stage 2. In particular, pupils should be taught to: • swim competently, confidently and proficiently over a distance of at least 25 metres • use a range of strokes effectively [for example, front crawl, backstroke and breaststroke] • perform safe self-rescue in different water-based situations. Pool-based lessons should teach children important water safety skills like treading water, safe exit and entry of the water and floating. We know, however, that some schools need additional support to deliver high quality swimming and water safety lessons: a recent omnibus survey by the Department reported that primary teachers who taught PE to key stage 1 and 2 pupils were generally confident planning, delivering, or supporting a PE lesson to improve a range of pupil outcomes. The exception, however, was in terms of planning, delivering, or supporting a PE lesson that improved swimming and water safety skills, in which a third of teachers (34%) were confident at key stage 1 and 46% of teachers at key stage 2. Swim England and the Swimming Teachers’ Association have recently published nine suggested skills to support schools to deliver lessons that will enable children to achieve the ‘perform safe self-rescue in different water-based situations’ attainment target. The nine suggested outcomes have been developed to address the skills required in common fatal accidental drowning scenarios. Water-based lessons can be complemented by classroom-based lessons that go further and cover aspects such as cold water shock, beach flags or the dangers of rip currents. There are a wide range of resources, programmes and support available from water safety organisations. The partnership the Department of Education has with swimming and water safety organisations, including the Royal Life Saving Society UK (RLSS UK), the Royal National Lifeboat Institution (RNLI), Swim England, Canal and River Trust, through our membership of the National Water Safety Forum Education working-group helps us to extend the impact of support and guidance for schools and parents. The working group is focussing on supporting schools and other providers to deliver engaging and consistent water safety messaging that is appropriate for the age and capability of children and young people throughout key stages 1 to 5. The Department has supported the RLSS UK’s annual Drowning Prevention Week to help raise awareness across schools. I was pleased to learn that RLSS UK report that this year’s campaign reached over 1.25 million children. I will take this opportunity to commit to the Department supporting the 2025 campaign to help more schools to participate. It is important that all children have the opportunity to learn to swim and know the dangers of water. We are funding the Inclusion 2024 programme, which is led by the Youth Sport Trust, to increase and improve opportunities for children with special educational needs and disabilities to take part in PE, sport and physical activity. The programme includes a specific project focussing on swimming and water safety, which is led by Swim England. A series of free tools, guidance and advice have been developed and are available on Swim England’s website. These resources are also being extended onto nasen’s Inclusive Education Hub, so they can reach more teachers. 2 The Primary PE and Sport Premium can be used by schools to improve their swimming and water safety provision. Schools can use their premium to provide top- up swimming and water safety lessons for children not able to meet the national curriculum expectation after core lessons, for teacher training or to provide a broader range of aquatic sports to pupils. Water safety should be part of every child’s education, with PE and RSHE providing good opportunities for practical and classroom-based learning. No family should have to endure the heartbreak of Joe and Sunnah’s families and I welcome further opportunities for the Department to work alongside them and sector organisations on awareness raising campaigns. Yours, Minister for School Standards 3
See every Prevention of Future Deaths report matching South West Ambulance Service NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.