Evidence
Date of report: 18/09/2024
Ref: 2024-0501
Deceased name: Peter Jeffery
Coroners name: Samantha Marsh
Coroners Area: Somerset
Category: Other related deaths
This report is being sent to: Sedgemoor District Council
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
---|---|
THIS REPORT IS BEING SENT TO:
Sedgemoor District Council |
|
1 | CORONER
I am Samantha Marsh, Senior Coroner, for the coroner area of Somerset |
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 13th November 2023 I commenced an investigation into the death of Peter Ivor Jeffery. The investigation concluded at the end of the inquest on the 10th September 2024. The conclusion of the inquest was death by Misadventure. The medical cause of death was: Ia) Drowning. I record that “Peter Ivor Jeffery, aged 68, jumped into the water by the jetty at Burnham on Sea beach around 3.30pm on the afternoon of Sunday 29th October 2023 to assist a stranger and her dog who were in distress in the water. He was fully clothed in jeans, trainers and a snug boiler suit, which negatively impacted on his ability to swim. Peter got caught in a riptide and was unable to be rescued by those |
4 | CIRCUMSTANCES OF THE DEATH
Peter Ivor Jeffery (“Peter”) was a relatively strong, fit and healthy 68 year old man. On the afternoon of the 29th October 2023, Peter went to the jetty at Burnham-on-Sea, somewhere that he’d been to previously and was reasonably familiar with, having been there before at different times and so he had experienced that part of the coast in different weather and seasonal conditions; although he had never been in the water, only observing the tide from the shore, which was something that he liked to do. (i) A warning about the potential risk posed by the sinking sand; Evidence was admitted by the rescue personnel that this area of water is known to be notorious amongst locals. I heard that signage and/or flags are displayed at the beach to advise against swimming in certain stretches of that part of the coast, but that these are only displayed in peak/summer season, and this incident happened out of season and so no flags or additional signage was in place. |
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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Whilst there are multiple signs in existence at the location, not all of these are for public safety, some focus on more ‘administrative’ matters such as the closure of gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly important in the smooth administration of the public space, the consequences of such are not life threatening and the size and prominence of such administrative signs and surprising when compared with the signage that conveys potentially life-saving information. I am concerned that the risks posed by entering the water (which appear equal to, if not greater than, the risks posed by the mud and sand) are not prominently and clearly displayed to those who lack local knowledge, especially out of ‘season’. This may cause people to misinterpret or underestimate the dangers posed by the undercurrent and rip-tides which, of course, are under the surface of the water and so not immediately obvious or visible. As such people may continue to make ill-advised decisions to enter the water; water which has the power and ability to overwhelm even the strongest of adult swimmers within seconds. |
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe the Council has 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 14th November 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: Mr Jeffery’s family |
9 | 19th September 2024 |
The post Peter Jeffery: Prevention of Future Deaths Report appeared first on Courts and Tribunals Judiciary.
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