Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 26 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2015 |
|---|---|
| Deceased | Robert Mansfield |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire and Pembrokeshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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: 1. Chief Executive Pembrokeshire County Council County Hall Haverfordwest Pembrokeshire SAQ61 1TP 1 CORONER I am Jonathan Mark Layton Senior Coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 29th July 2015 I commenced an investigation into the death of Robert Alan Mansfield then aged 18. The investigation concluded at the end of the inquest on 26th November 2015. The conclusion of the inquest was accidental death. 4 CIRCUMSTANCES OF THE DEATH (1) Robert Alan Mansfield entered the Millpond whilst out celebrating his 18th birthday. (2) His friends called for assistance when they became concerned for his welfare. (3) Emergency services have attended but could not locate Mr Mansfield. (4) His body was subsequently recovered. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this 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 is as follows: That there have been three deaths at the location in a matter of months giving rise to concerns about the safety of the Millpond. In particular the potential need to fence some areas, improve lighting, consider the adequacy of warning notices and the availability of flotation equipment are matters requiring consideration and attention. 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, 1 namely by the 21 January 2016. 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 am also under a duty to send the Chief Coroner a copy of your response. 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 26 November 2015 Signed: J M Layton 2
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