David Ejimofor

His Majesty’s Assistant Coroner for the Coroner Area of Swansea and Neath Port Talbot  

City and County of Swansea Civic Centre 

Oystermouth Road  

Swansea  

SA14SN  

Delivered by email 

Dear Sir 

30 July 2025  

Re: Regulation 28 Report: David Chiaka Ejimofor  

Associated British Ports wish to thank the Coroner for writing to our Chief Executive and bringing 

to our attention the various matters of concern that were prompted by his investigation into the 

tragic  death  of  David  Chiaka  Ejimofor.    Associated  British  Ports  express  their  sympathy  to  the 

family of David Chiaka Ejimofor.  

I am responding on behalf of the Chief Executive and confirm that the Chief Executive has seen 

and approved this response. 

It  should  be  noted  that  this  response  is  based  entirely  on  the  Regulation  28  Report  that  was 

received.  

We acknowledge the Coroner's concerns and recommendations and are committed to working 

collaboratively with Neath Port Talbot Council (NPTC) and the Royal National Lifeboat Institution 

(RNLI).  

We will seek to respond to the point of deterrence measures (including signage and a limited height 

barrier) that has been raised by the Coroner's concerns and to identify any changes to signage, 

barriers and/or fencing at the breakwater to mitigate the risk of any future death by undertaking a 

signage, fencing and barrier review and implementing any necessary actions identified by such 

review. The review has commenced and will risk assess each option to ensure that by reducing 

one risk it does not create another. The initial review is anticipated to be concluded by the end of 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 July 2025. The maintenance  inspections of the breakwater will continue and Associated British 

Ports will consider the findings of each inspection to determine whether a further review of the 

deterrence measures is required. 

For a second successive year, Associated British Ports has deployed an additional security officer 

to monitor the whole of the Port Talbot Estate during the summer months. 

Associated British Ports have been informed via NPTC that the RNLI have been monitoring the 

breakwater. 

Associated British Ports are repeating this summer an awareness communication that has been 

run in previous summers warning of the dangers of water. The communication is posted on various 

media to include Instagram.  

Associated British Ports have no record of a lifeguard being located on the breakwater at times of 

higher risk. 

We  trust  that  the  information  provided  demonstrates  Associated  British  Ports’  commitment  to 

working  to  prevent  future  incidents  in  this  area  and  to  working  collaboratively  with  other 

stakeholders. 

Yours faithfully 

Chief Commercial Officer and Regional Director, Wales and Short Sea Ports 

Associated British Ports 

`

30th July 2025 

Dyddiad/  Date 
Rhif  Ffôn/  Direct Line 
Ebost/  Email 
Cyswllt/  Contact 
Eich cyf /  Your ref  David Chiaka Ejimofor 

Ein cyf/  Our ref 

HM Senior Coroner for Swansea and Neath Port 
Talbot 
The Guildhall 
Swansea 
SA1 4PE 

By email: 

 and 

Dear HM Senior Coroner for Swansea and Neath Port Talbot 

Regulation  28  Report  to  Prevent  Future  Deaths  –  David  Chiaka  Ejimofor 
(Deceased)  

This  is  Neath  Port  Talbot  County  Borough  Council’s  (NPTCBC)  response  to  the 
report  raised  by  HMAC  Ramsay  following  the  inquest  into  the  tragic  death  of 
David  Ejimofor  by  drowning  having  jumped  into  the  Sea  at  the  Small  Beach, 
Aberavon from the breakwater owned by Associated British Ports (ABP).  

Our  thoughts  continue  to  be  with  David’s  family  and  friends  following  this 
incident.    

NPTCBC has continued since the inquest hearing to engage in dialogue with the 
landowners,  ABP,  and  our  contracted  specialists  the  Royal  National  Lifeboat 
Institution  (RNLI).  As  the  inquest  was  told,  RNLI  are  continuing  through  this 
season  to  undertake  intensive  monitoring  and  assessment  around  the  small 
beach  area,  including  insofar  as  it can  the  breakwater,  in  order  to  identify  the 
required provision for lifeguarding services. 

Pennaeth Gwasanaethau Cyfreithiol 
Y Ganolfan Ddinesig, Port Talbot SA13 1PJ 
DX 135226 Port Talbot 2 

Head of Legal Services 
Civic Centre, Port Talbot, SA13 1PJ 
DX 135226 Port Talbot 2 

 
 
 
 
 
 
 
  
 
  
 
  
 
 NPTCBC  will  continue  its  dialogue  with  RNLI  in  particular  but  also  with  ABP. 
NPTCBC  will  be  led  by  RNLI’s  recommendations  in  view  of  their  nationally 
recognised expertise and will continue to address recommendations as far as is 
practicable within resource and budgetary constraints. ABP’s engagement with 
RNLI  as  to  provision  of  services  on  the  breakwater  itself  is  beyond  NPTCBC’s 
knowledge.  

Turning to address the specific concerns raised by the Coroner:  

There are no lifeguards stationed at the breakwater during high risk period in the 
spring and summer months (when the weather is good and the tides high), when 
children and young people have been seen/known to jump into the water from it.  

There is no duty in law on NPTCBC to provide lifeguards at beaches. Nonetheless, 
as  HMAC  is  aware,  NPTCBC  engaged  RNLI  to  assess  the  appropriate  level  of 
lifeguarding  provision  along  the  Aberavon  seafront  and  upon  its  areas  of 
ownership. It is not possible to have lifeguards stationed right across the beach at 
Aberavon, or at all beaches within the NPTCBC area, and so provision is targeted 
and public are reminded to look out for lifeguard provision and to, for instance, 
swim between the flags.  

NPTCBC cannot police access to the breakwater, whether by lifeguard provision 
or otherwise. The breakwater is outside NPTCBC’s ownership.  

There are ongoing discussions between NPTCBC, RNLI and ABP seeking to identify 
and  where  possible  implement  measures  which  would  help  to  reduce  risks  to 
people  who  use  the  beach  and  those  who  choose  and  are  able  to  access  the 
breakwater and the sea from off the breakwater.  

2 

 
 
  
  
  
 
 
 
 As noted above, the RNLI is currently undertaking an exercise to monitor activity 
in  the  vicinity  of  the  breakwater. These monitoring  efforts  and discussions  are 
expected to continue across the summer 2025, to help inform a formal review of 
the  Beach  safety  assessment  and  in  turn  a  decision  regarding  lifeguard 
deployment for the 2026 summer season. Should it ultimately be determined that 
additional  lifeguard  coverage  is  necessary,  NPTCBC’s  intention  would  be  to 
implement  this  provision  during  2026  subject  to  the  necessary  funding  being 
available. 

NPTCBC will of course share assessment of the risks identified along the beach in 
RNLI’s assessment with APB.   

Jumping from, and the water around, the breakwater is known to be dangerous  

NPTCBC recognises that jumping from the breakwater into the sea is a dangerous 
activity. It is obviously so. NPTCBC cannot police access to third party owned land 
and does not own or exercise any control over the breakwater.  

As  previously  outlined,  discussions  are  ongoing  regarding  the  potential 
implementation  of  additional  water  safety  measures  and  interventions  in  the 
vicinity  of  the  small  beach  to  improve  and  support  public  understanding  of 
hazards associated with this stretch of coastline, and where possible to provide 
methods of assistance for anyone who may get into difficulty.  

The practice of placing a lifeguard at the breakwater at times of higher risk in the 
spring and summer months had been in place historically and was known to be 
effective at reducing the risk.    

It  remains  NPTCBC’s  position  that  lifeguards  have  not  been  stationed  at  the 
breakwater  for  well  over  a  decade,  with  no  evidence  to  suggest  the  risk  has 
worsened  over  that  period.  David’s  activity  in  accessing  the  breakwater  and 

3 

 
 
  
  
 
  
  
 jumping into  the sea  was  in  any  event  outside  of  the hours at  which  lifeguard 
provision  would  have  operated.  Nevertheless,  dialogue  will  continue  between 
NPTCBC, RNLI and APB and once the outcome of the RNLI monitoring exercise is 
available it will of course be taken into account in identifying what, if any, further 
measures are appropriate to be taken. 

Why lifeguards had been removed from the breakwater prior to David’s death 
and why that measure continues to be absent today.  

As outlined at the inquest hearing, lifeguards were not regularly stationed at the 
breakwater  but  would  occasionally  pass  there  as  part  of  a  patrol.  Lifeguard 
provision and arrangement for its implementation was changed over a decade 
ago, since when RNLI, as the national experts in lifeguard provision were engaged.  

RNLI undertook its own beach safety assessment upon its engagement to provide 
services  and  since  then  has  been  provided  with  funding  to  implement  the 
recommended level of services. 

The current Beach safety assessments continue to recommend services along the 
Aberavon  beach  front  area  encouraging  and  instructing  the  public  to  swim  at 
lifeguarded areas and during lifeguarded times. NPTCBC awaits the outcome of 
RNLI’s  current  monitoring  and  risk  assessment  period  following  which,  if 
recommended,  changes 
in  service  along  the  beachfront  area  will  be 
implemented.  If  there  are  no  changes  implemented  NPTCBC  will  continue  to 
provide 
the  current  RNLI 
recommendations.   

lifeguarding  provision 

line  with 

the 

in 

4 

 
  
  
 
 
  
 
 
 
 
 Evidence  that  other  deterrence  measures  put  in  place  since  David’s  death  are 
working effectively to reduce the risk.    

Monitoring of the breakwater is ongoing. Once the analysis is complete, NPTCBC, 
in cooperation with RNLI and ABP, will be able to assess whether any additional 
deterrent measures are necessary to effectively reduce the identified level of risk 
still further.  

NPTCBC remains firmly committed to working in close collaboration with RNLI and 
ABP  to  mitigate  identified  risks  in  this  specific  area.  We  continue  to  advance 
measures aimed at preventing any recurrence of incidents of this nature.  

Following  the  conclusion  of  the  ongoing  monitoring  and  once  determinations 
have  been  made,  a  further  update  will  be  provided  to  HM  Senior  Coroner  for 
Swansea Neath and Port Talbot.  

Yours faithfully, 

Head of Legal and Democratic Services  

5

Mr Edward Ramsay   
His Majesty's Assistant Coroner for Swansea and Neath Port Talbot  
The Guildhall  
Swansea  
SA1 4PE  

    29 July 2025 

Dear Mr Ramsay,   

Re: Regulation 28 report to Prevent Future Deaths  
DAVID CHIAKA EJIMOFOR  

Thank you for your report to our Chief Executive regarding the death of David Chiaka Ejimofor and for 
setting out your concerns.  

As the Chief Operating Officer at the RNLI, I am responsible for the lifeguarding service and as such I am 
responding on behalf of the Chief Executive.   

As set out at the inquest, although the RNLI chooses to provide lifeguarding services, it has no legal duty 
to do so.  Importantly, it cannot provide any service without the landowners or the occupier’s request or 
consent.  It is entirely a matter for the landowner or occupier whether they ask and contract with the 
RNLI to provide a lifeguarding service.   

However following the inquest, the RNLI is taking two actions:  

1.  Undertaking daily monitoring of people using:  

i. 
ii. 
iii. 

Aberavon beach  
Little Beach (the beach to the left of the breakwater if looking out to sea)   
The breakwater   

The monitoring started on Saturday 24 May 2025 and takes place between 10:00 and 19:30.  

The purpose of the daily monitoring is to understand how many people are using Little Beach and, 
importantly, how many people are entering the water from the breakwater. This will allow the RNLI to 
make recommendations to its partner, Neath Port Talbot Council.     

The monitoring will continue for the remainder of the 2025 Lifeguarding Season. Following completion 
of the season, a report will be prepared with recommendations.   

 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
 2.  We will work collaboratively with Neath Port Talbot Council and Association British Ports given 

the Coroner’s concerns.  

In considering what action the RNLI will take, or recommend, we will take into account the wider issues 
which are set out below.  

The Lifeguarding Challenge   

As discussed at the inquest there is no statutory requirements for a landowner to contract for a beach 
lifeguard service.  Even if it was a statutory requirement, it is improbable or more accurately impossible, 
that all beaches could be lifeguarded and even if they were it would be for defined seasons and defined 
times of day.  

Further, the UK has:  

•  Over 7,000 miles of coastline (depending on how it is measured)  
•  1,500 listed beaches  
•  600 designated bathing waters, mostly beaches  

Currently the RNLI is the largest provider of lifeguard services and in 2025 will patrol 249 sites on behalf 
of a range of clients, predominantly local authorities. There are fewer than 300 lifeguarded beaches 
across the UK.   

It should be noted that the RNLI does not independently provide any lifeguard services that are not 
linked to clients and currently the RNLI does not have a contractual relationship with the owner of the 
breakwater.  

Specific to jumping from structures into the water  

Jumping from varying heights into water occurs from both natural and manmade structures all around 
the UK. In a controlled activity it is referred to as coasteering and as uncontrolled/unregulated activity it 
is referred to as tombstoning.  

The National Water Safety Forum (NWSF) states that ‘It is important to recognise that tombstoning is an 
activity that has occurred around the coast for generations. Unfortunately, over recent years it has 
gained attention for the wrong reasons, with a number of people being killed or seriously injured. The 
title was adopted because of the way a person falls and plunges into deep water, in a similar way a 
stone would. Tombstoning is typically undertaken by individuals, with varying degrees of planning and 
formality attached. Quite often, the media will use the tag 'tombstoning' to describe a wide range of 
activities where people jump into the water from height.’  

 
 
 
  
 
 
 
  
 
 
 
 
 Restricting access or even universal provision of signage at all possible sites would be almost impossible 
and, in many locations, would prove to be highly unpopular. 

The UK has:   

•  100’s of miles of coastal paths  
•  433 official harbours  
•  62 seaside piers  
•  There are 100s of breakwaters of various designs, many that provide access to deeper water 

locations from the beach  

•  On usually a smaller scale, but often presenting the same management issues there are 1,000s of 
groynes and other sea defences, many that also provide access to deeper water locations from 
the beach  

Restricting access   

Options that restrict access such as fencing would be cost prohibitive and are likely to be defeated by 
individuals swimming or wading around the obstacle. Restricting access to aquatic locations is counter 
to the general principle of facilitating access to green and blue spaces.  

The National Water Safety Forum (NWSF) has published principles for managing water related risks, the 
fundamentals of which include, that:  

•  No activity can be made completely risk-free.   
•  As far as possible, avoid restricting access to water spaces or facilities.  
•  As far as possible, avoid additional regulatory controls.   

Lifeguards are normally deployed to facilitate bathing rather than preventing aquatic activities. If solely 
deployed to stop access it would be more appropriate to deploy a security guard or warden service.  

Given the above challenges core swimming and self-rescue skills are important.   

Core swimming and self-rescue skills  

A key element of an individual’s safety in water is their swimming ability. The requirement in the UK is 
that all schools must provide swimming instruction either in key stage 1 (children 5-7 years old)) or key 
stage 2 (children 7-11 years old).  

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 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  

Unfortunately, not all children are achieving against the prescribed standard and a 2023-24 academic 
year report states that only 70% of Year 7 pupils (aged 11-12) can swim competently, confidently and 
proficiently over a distance of at least 25m.  

Summary   

The RNLI will progress with the two actions set out above.   

Further the RNLI acknowledges that anyone can drown but no one should, and David’s death was a 
tragedy. The RNLI is a charity that works to end preventable drowning, and we will continue to 
influence, supervise and educate people and explain the risks and share safety knowledge with anyone 
going out to sea or to the coast.     

Yours sincerely,  

Chief Operating Officer & Director of Regions, RNLI