Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0521, written 16 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2025 |
|---|---|
| Reference | 2025-0521 |
| Deceased | Theo Treharne-Jones |
| Coroner | Gavin Knox |
| Coroner area | South Wales Central |
| Category | Child Death (from 2015) · Other related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW 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: TUI UK Limited Association of British Travel Agents (ABTA) CORONER 1 2 3 I am Gavin Knox HM Coroner, for the coroner area of South Wales Central. 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. INVESTIGATION and INQUEST Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW On 25 June 2019 I commenced an investigation into the death of Theo Phillip TREHARNE- JONES . The investigation concluded at the end of the inquest on 15 October 2025. The conclusion of the inquest was Accident. 1a Drowning 1b 1c II CIRCUMSTANCES OF THE DEATH These were recorded as :- 4 Theo Treharne-Jones died on 15 June 2019 by drowning in a swimming pool at The Holiday Village Atlantica, in Kos Greece where he was on holidays with his family. Theo was 5 years old. He could not swim and as a result of a genetic condition had no sense of danger. He accessed the swimming pool, which had no protective barrier, after leaving his hotel room unnoticed while his parents were asleep. The hotel room locks were of a design that did not secure against Theo leaving the room. 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. Theo was particularly vulnerable in that: 5 1. He had developmental delay; 2. He had no sense of danger; 3. He was prone to waking during the night; 4. He was fully mobile; 5. He loved swimming and had some sensory needs; 6. He was unable to swim. The door locks in the hotel room were of a design to promote safety during a fire and could be easily disengaged from the inside; There was no secondary security measure such as a chain in place; Theo’s parents recognised the risk of Theo leaving the room unsupervised and attempted to Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW mitigate this by locking the door and putting additional impediments in the way of the door including 2 pushchairs and an empty suitcase; ABTA guidance does make reference to a security chain/latch but this is the context of enabling customers to identify a visitor at the door and merely states such could be provided. However, there is no reference in the guidance to any form of security in the sense of controlling the exit from the room. No specific information about door locks and security chains was given to Theo’s parents on booking or on arrival. The pool that Theo was found in did not have any physical barrier in place to prevent uncontrolled or unsupervised access by children. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th December 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. COPIES and PUBLICATION I have sent a copy of my report to family who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 6 7 8 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. Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 16 October 2025 SIGNED: 9 Gavin Knox HM Coroner for South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
S A B T A Travel with confidence ABTA Ltd 30 Park Street, London SE1 9EQ T: +44 (0)20 3117 0500 | E: abta@abta.co.uk | www.abta.com 27 November 2025 Graeme Hughes His Majesty's Senior Coroner South Wales Central Coroner Area Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Mr Hughes Thank you for your letter concerning the sad accidental death of Master Theo Phillip Treharne-Jones in June 2019. We write in response to the Regulation 28 Report to Prevent Future Death in which Gavin Knox HM Coroner named ABTA as an interested party. We have carefully reviewed the report and your request for action. I thought it would be helpful to firstly outline the purpose and role of ABTA. We are a trade association representing and providing services to our members, who make up a significant part of the UK travel industry and who sell a range of travel services including package holidays, flights, accommodation, and car hire. ABTA provides services to consumers through our customer support and arbitration services which deal with a range of consumer issues involving ABTA members. ABTA also fulfils a self-regulatory role in respect of its members through its Code of Conduct and financial protection mechanisms. Concerning health, safety, and security, we provide guidance to members and raise awareness on safety issues with consumers and destination authorities. I should point out, however, that there are many travel providers who are not ABTA members. Any company that is not an ABTA member would not have access to the advice and guidance we provide to our members on health and safety matters, or other topics. In addition, UK travellers could visit destinations without using a UK travel agent or tour operator (either ABTA member or otherwise) to make their travel arrangements. ABTA regularly convenes a committee of Health and Safety leads from UK tour operators. We bring them together to discuss and review incidents and issues that consumers have faced while on holidays, using evidence-based information to shape guidance to members and consumers. We also collaborate with consultants and destination authorities and external stakeholders, such as the FCDO, to help consumers avoid issues overseas. Registered in England No. 551311 EClAA THE EUROPEAN TRAVEL ASENTS' AMO TtlUfi OPERATORS' ASSOCIATIONS Local standards and regulations with regards to safety, health, hygiene, and security vary from country to country, and even from region to region, and there is no globally recognised tourism accommodation health and safety standard. As part of our ongoing commitment to support improvement within the tourism accommodation sector, through collaboration with our members and a team of health, safety and security specialists, ABTA has produced a guidance publication called the ABTA tourism accommodation health & safety technical guide. The first edition of the guide was developed in 2000/1 and is reviewed every five years; the current 2023 version is available in English and eight other languages including Greek. The guide does not seek to supersede or replace standards stipulated by local law and regulation, but in the absence of overarching international standards, it is designed for use by ABTA members, Ministries of Tourism, destination authorities, hotel associations and associated accommodation suppliers to support and assist them with a suggested pragmatic approach to their safety management processes. The guide is intended to assist suppliers in the development of their own safety and risk management programme, to be used in conjunction with their own programme for compliance with local, regional, and national safety legislation. Within the security section of the guide there is information relating to door locking mechanisms, I have included relevant extracts for your reference: Security provisions should be provided within sleeping accommodation to help prevent access by intruders. (cid:127) All customer room doors should be secured with an adequate locking system. Ideally doors should lock automatically when they are closed and open only with a key or electronic key card. (cid:127) Doors should befitted with a double lock or dead bolt for use internally when customers are in their rooms to provide additional security. (cid:127) To enable customers to identify a visitor at the door, a spy hole or security chain/latch could be provided. (cid:127) Windows and balcony doors in the customer room should be provided with locking devices Within the fire safety section for all building types 1-5, the means of escape section of the guide includes information relating to the entrance doors of rooms and apartments and I have included relevant extracts for your reference: (cid:127) Entrance doors rooms and apartments should be easy to open from the inside at all times. We have considered your recommendation and in our view the recommendation of security chains for any other reason than highlighted above could inadvertently create fire safety risks and hamper customer evacuation in an emergency. We will continue to work with our members and other stakeholders to make this guidance available to travellers. We are not aware of the full facts in the specific case which is the subject of your report and therefore we are unable to comment any further regarding the tragic accidental death of Master Theo Phillip Treharne-Jones or the safety provisions provided at the accommodation. We wish to offer our sincere condolences, through your office, to his parents and wider family and friends. Yours sincerely, Chief Executive Officer ABTA - The Travel Association
TUI Mr Gavin Knox, HM Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW United Kingdom Dear Mr Knox 04 December 2025 Thank you for your Prevention of Future Deaths report dated 16 October 2025. Before responding to your concerns, and whilst I am aware that TUI UK passed on its condolences through the Inquest process, I would like to personally express my sympathy to the family of Theo and my sadness at his death. Your report has been considered at one of TUI Groups Safety and Risk meetings (and as you are aware relevant matters had been considered in advance of the Inquest). I have since considered, and following this careful and thorough review we have decided not to take any further action. I set out reasons for that below. In essence it is considered that any action which could be taken is likely to create significant and unacceptable risk, particularly in relation to fire. I am aware that during the Inquest, reference was made to the Tourism Accommodation Health & Safety Technical Guide produced by ABTA. That guide was updated by ABTA in 2023 following their consultation with various industry experts. The guidance remains the materially the same as that in the 2017 guidance which was before you as regards relevant risks arising from this matter. In relation to Fire Safety, there are different building types considered in the guide, and at the Inquest, the relevant building was type 2 (type 1 are single dwellings, the other types are classic hotel blocks of different configurations). The wording for Type 1 buildings is that, “All doors should be easy to open from the inside at all time and should always be unobstructed” , and for Types 2 to 5, “Entrance doors to rooms and apartments should be easy to open from the inside at all times”. TUI AG | Karl-Wiechert-Allee 23 | 30625 Hannover | Germany Marc Jordan I Marc.Jordan@tui.com | www.tui.com TUI G R O U P | TUI AG | Karl-Wiechert-Allee 23, 30625 Hannover | Postfach 61 02 09, 30602 Hannover, Deutschland Tel. +49 511 566-00, Fax +49 511 566-1901 | www.tuigroup.com Vorsitzender des Aufsichtsrates: Dr. Dieter Zetsche | Vorstand: Sebastian Ebel (Vorstandsvorsitzender), Mathias Kiep, Peter Krueger, Sybille Reiss, David Schelp Sitz der Gesellschaft: Berlin/Hannover | Handelsregister: Amtsgericht Berlin-Charlottenburg HRB 321 | Amtsgericht Hannover HRB 6 580 | Ust-ld.Nr. DE 115653127 Bankverbindung: Commerzbank AG | IBAN DE53 2504 0066 0310 8958 00 | BIC (SWIFT) COBADEFF250 Bankverbindung: Deutsche Bank AG | IBAN DE52 2507 0070 0054 5459 00 | BIC (SWIFT) DEUTDE2HXXX Bankverbindung: UniCredit Bank AG | IBAN DE46 7002 0270 0000 2809 04 | BIC (SWIFT) HYVEDEMMXXX TUI Seite 2 Datum 04 December 2025 In relation to other doors, for example, on corridors leading from/to rooms, the guidance is that doors should open in the direction of escape, and be easy to open from the inside at all times without the use of a key. In relation to Security, the guidance is that security provisions should be provided within sleeping accommodation to help prevent access by intruders. To enable customers to identify a visitor at the door, a spy hole of security chain/latch could be provided, but as discussed at the Inquest, the purpose of a chain/latch is to enable a customer to identify a visitor. If a chain/latch is present, and I accept that they may be present in some rooms at some accommodation, permanent use militates against fire safety guidance. Having reviewed and considered carefully we are of the opinion that if all rooms were provided with security locks/chains (or other devices designed to control exit), that would significantly increase the risk of harm in the event of a fire or other emergency, as swift and easy exit from the room in an emergency would be hindered. We are not aware of any form of device that could control exit from the room, and at the same time, not prohibit swift exit from the room during a fire or other emergency. I should point out that we insist upon locking mechanisms on patio doors etc, that lead directly on to “swim up pools”, in essence from the “back door” of the room, not the primary exit in the event of an emergency. This is to guard against the risk of unsupervised access to a pool, that probably does not have lifeguard provision, immediately outside the room. It does not impact the ability of the room occupants to escape in the event of an emergency. In relation to communal pools, (and generally), hotels and other accommodation providers need to comply with local standards. Evidence was provided to you at the Inquest as regards the local standard in Greece relating to pool barriers etc, and evidence as regards the increased risk that can be created with such barriers (for example, being trapped unseen beneath pool covers, falls etc from climbing on fences). We do not provide guidance as to locks on room doors. We provide information to comply with the relevant statutory regulations. We also invite customers (or potential customers) through the safety advice hub on our website to contact us if they have TUI Seite 3 Datum 04 December 2025 questions re safety, and booking documents invite customers to contact their Rep in resort for help or guidance. As I said at the outset of this response, I am terribly sorry for Theo and his family for this tragic event. Whilst at present we do not consider that we can take action, as that will unreasonably increase other risks, we will keep this under review. TUI GroupX Director'Group Security, Health & Safety, Crisis & BCM
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