Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0183, written 10 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2025 |
|---|---|
| Reference | 2025-0183 |
| Deceased | Joel Ineson |
| Coroner | David Place |
| Coroner area | Sunderland |
| Category | Accident at Work and Health and Safety related deaths · 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.
David Place Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: SECRETARY OF STATE FOR CULTURE, MEDIA AND SPORT CHIEF EXECUTIVE OF THE HEALTH AND SAFETY EXECUTIVE 1 CORONER I am David Place, His Majesty’s Senior Coroner for the City of Sunderland 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 2nd June 2023 I commenced an Investigation into the death of Mr Joel Kennth Ineson, who died at Hetton Lyons Park, Downs Pit Lane, Hetton-le-hole, Houghton-le-Spring on 1st June 2023 aged 55 years. The Investigation concluded at the end of the Inquest on 4th April 2025. I gave a conclusion of ‘Accident’, and the medical cause of death having been revealed by the post-mortem examination, was confirmed as: - Ia Drowning Ib Diffuse Myocardial Scarring 4 CIRCUMSTANCES OF THE DEATH Joel Kenneth Ineson died at Hetton Lyons County Park on 1st June 2023 by drowning, having participated in an open water swimming event and suffering an unexpected cardiac event. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed a matter 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: – Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for HM Coroner’s Courts, City Hall, Plater Way, Sunderland SR1 3AA Tel 0191 5617843 email: coroner@sunderland.gov.uk | web: www.sunderlandcoroner.co.uk an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths, and I believe you 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 5th June 2025. 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: - • Family • Sunderland City Council and their Solicitors • Springboard Sunderland Trust and their Solicitors • Organiser of water-based activity and their Solicitors I have also sent it to the following who may find it useful and of interest: • The Royal Society for the Prevention of Accidents Page 2 of 3 I am also under a duty to send the Chief Coroner and all interested persons, who in my opinion should receive it, a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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 this 10th day of April 2025 Signature: HM Senior Coroner for the City of Sunderland Page 3 of 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.
Minister for Sport, Media, Civil Society and Youth Department for Culture, Media and Sport 1st Floor 100 Parliament Street London SW1A 2BQ E: enquiries@dcms.gov.uk www.gov.uk/dcms 22 May 2025 David Place His Majesty's Senior Coroner for the City of Sunderland Sunderland City Hall Plater Way Sunderland SR1 3AA Dear Mr Place, Thank you for your email of 10 April 2025 enclosing a Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Joel Ineson. I am replying as the Minister for Sport. Please allow me to pass on my sincere condolences to the family and friends of Mr Ineson for their loss. This was a tragic event, and I share your desire to ensure that all possible lessons can be learned. The safety and wellbeing of everyone taking part in sporting events is of paramount importance, and I will continue to push sports and event organisers to do everything they can to prioritise this. As your report notes, the swimming event at which Mr Ineson lost his life was run by an organisation that was not affiliated to the National Governing Body (NGB) for swimming, Swim England. NGBs have jurisdiction over events run by organisations affiliated with them, but it is not mandatory for clubs or events to be affiliated with an NGB. Regardless of affiliation, event organisers should ensure that they are doing all they can to ensure the safety of participants, and must meet any legal obligations under statutory and/or common law that apply. To help with this, Triathlon England, Swim England, Swim Wales, and Welsh Triathlon, along with the Royal Life Saving Society, have created “Beyond Swim”, an accreditation scheme for open water venues. The scheme focuses on safety to ensure open water swimming operators are following best practice guidelines and implementing robust safety standards. Beyond Swim provides information for venue operators and event organisers to help them assess and improve their safety standards. In addition to this, Swim England recently announced the introduction of the first training course specifically for open water swimming leaders. The SEQ Level 2 Outdoor Swimming Leader Qualification covers the essential knowledge and leadership skills required to enable individuals to confidently risk assess, plan, prepare and lead safe and effective outdoor swimming sessions for small groups. These are positive steps but, as your report highlights, it is important to ensure good awareness of safety standards in open water swimming. I will therefore write to Swim England to explore how awareness of “Beyond Swim” and associated guidance and support can be increased, and ask them to report back to me. More generally, I will continue to work with sports bodies to ensure that safety is prioritised. Thank you again for your consideration of this issue and for bringing it to my attention. Yours sincerely, Minister for Sport, Media, Civil Society and Youth
Health and Safety Executive Chief Executive Redgrave Court Merseyside L20 7HS http://www.hse.gov.uk/ Mr David Place, His Majesty’s Senior Coroner for the City of Sunderland By email: 02 June 2025 Dear Mr Place, REGULATION 28 PREVENTION OF FUTURE DEATHS – OPEN WATER SWIMMING Thank you for your Regulation 28 report in relation to the death of Mr Joel Kenneth Ineson, who sadly died while participating in an open water swimming event at Hetton Lyons County Park on 31st May 2023. Your report raises as matters of concern, that: - - - there is no established body for regulation of the activity; there is no specific health and safety guidance for the activity; and there is no licence from the Adventure Activity Licencing Authority (AALA). I will address each of these points in turn. Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks. Businesses are also required to appoint one or more competent persons with the skills, knowledge and experience to recognise hazards and to assist with putting into place effective measures to protect workers and others from harm. When assessing and managing risk, businesses should take account of relevant guidance. To help businesses comply with the law, HSE provides general guidance on health and safety such as HSE’s health and safety basics for your business (https://www.hse.gov.uk/simple-health-safety/index.htm) as well as targeted guidance for higher-risk industries and activities. HSE does not seek to provide guidance for all industries and activities as it is often the case that others are more knowledgeable or better placed to provide such guidance. The risks associated with open water swimming are well known and relevant guidance is available from multiple authoritative sources such as the Amateur Swimming Association (ASA) and British Swimming (The_management_of_open_water_swimming_events.pdf), the National Water Safety Forum (https://www.nationalwatersafety.org.uk/adviceresources/open-water-swimming ) and British Triathlon (Microsoft Word - British Triathlon Open Water Swimming Safety Guidelines 08.doc). In addition, guidance is available from some local authorities such as that provided by Wigan Council (Open Water Safety Guidance). The Adventure Activities Licensing Regulations 2004 have a very specific purpose and were never intended to apply to all adventure activities or adult adventure activities. The Adventure Activities Licencing Authority (AALA) licence is aimed at those who provide tuition in specified adventure activities to children, and therefore it was not relevant to a swimming event for adults. It is HSE’s view that the regulatory provisions in place requiring those organising open water swimming events for the public to manage risks, together with the guidance available from multiple sources on the main risks involved, provide a suitable basis for businesses to provide activities safely and for regulators to take action where required. Consequently, HSE will not be publishing specific guidance at this time for open water swimming events for the public. HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area. To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm). I hope that the above information addresses the matters raised. Yours sincerely Chief Executive
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