Sedgemoor District Council
Bridgwater House 
King Square 
Bridgwater 
Somerset 
TA6 3AR 

I am Samantha Marsh, Senior Coroner, for the coroner area of Somerset

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.

On the 13^th November 2023 I commenced an investigation into the death of Peter Ivor Jeffery. The investigation concluded at the end of the inquest on the 10^th 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 29^th 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 
on the beach. This section of water is known to be particularly treacherous. 
Peter’s  body was discovered near to Stert Island on the 12^th November 2023.” 

Peter Ivor Jeffery (“Peter”) was a relatively strong, fit and healthy 68 year old man. On the afternoon of the 29^th 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. 
Whilst at the jetty on this occasion, Peter noticed a woman (a complete stranger to  him) and her dog who were in difficulty in the water; the dog had entered the water  and got into difficulty and so its owner had gone in after it, also finding herself in  difficulty. The lady had never been to this location before and was not familiar with it as she resides in another part of the country.  Peter, without hesitation, jumped into the water to try and help but was immediately  overcome by the water.  He went under. There were differing witness account as to whether or not he resurfaced shortly after entering the water but, if he did, it was not more than once.     An off-duty emergency service personnel and the specialist rescue service personnel (who by coincidence were at the scene) both declined to enter the water without  appropriate safety measures as they were aware of the dangers posed by the current and tip tides in this area and were aware that they would have been putting their own  lives at risk by doing so.   The specialist rescue personnel gave evidence from his eighteen years of experience of this part of the coastline that the tide/under-current can sweep a grown man away  in seconds as the water has the power to drag them under and there is no time to do  anything about it, it doesn’t matter how strong an individual is or how competent they  are in the water.  Peter was not seen again and a coastal search was coordinated to try and locate his body. He was eventually located some two weeks later near to Stert Island.   I admitted pictorial evidence showing the signage that is currently displayed on the walls and railings at the entrance to the Jetty. These showed or conveyed the  following messages: 

(i) A warning about the potential risk posed by the sinking sand;
(ii) A warning not to park a vehicle on the jetty;
(iii) A warning that the gates to the jetty may be closed during high tide;
(iv) Signs displaying varying warning triangles; this does include warnings about the  mud, sinking sand and risks posed by the tide.

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. 

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.

In my opinion action should be taken to prevent future deaths and I believe the Council has the power to take such action.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by 14^th 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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

Mr Jeffery’s family 
Burnham on Sea Lifeboat station 
Burnham on Sea Search and Rescue (BARB)
 
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.    
I may also send a copy of your response to any other person who I believe may find it useful or of interest.  
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.