Raymond Mills: Prevention of Future Deaths Report

The Department for Transport

I am Samantha GOWARD, Area Coroner for the coroner area of Norfolk

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 22 August 2024 I commenced an investigation into the death of Raymond Barrie Thomas MILLS aged 74. The investigation concluded at the end of the inquest on 22 January 2025.

The medical cause of death was:
1a)       Ischaemic Heart Disease and Drowning

The conclusion of the inquest was:
Died due to accident caused by underlying natural causes.

In summary, on the 17th of August 2024 Mr Mills went to view a shipwreck off the coast of Brancaster beach in Norfolk. While doing so he went under the water when the tide came in and a search operation was launched by the Coast Guard.  He was sadly found unresponsive in the sea and despite attempts to revive him, he died after being airlifted to the local airport.

At the Inquest concern was raised by Mr Mills’ family that there was not actually a sign at the site of the shipwreck warning of the dangers of the tides at the wreck. Reference was made to some signs which are pictured online, but it was unclear to me whether they were current and in place and in a bundle of photographs that had been provided by the National Trust with warning signs, they did not provide photographs of any signs at the site of the wreck. I was unclear if this was because they are no longer there or just that they did not realise these may be of assistance.

As this issue was raised at the hearing and we had not had the opportunity to ask the questions of National Trust prior to this, I was unclear whether my obligation under Regulation 28 had been triggered.  I therefore indicated that I would write a letter to obtain more information and decide upon receipt of that response.

This however then triggered a whole series of correspondence, the outcome of which, is that no one seems to know who is responsible for the shipwreck.

During the course of the investigation my inquiries 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.

While such a report should normally be issued within 10 working days of the conclusion of the Inquest, it has taken until now, having made attempts after the inquest to establish the answer to concerns raised, and I therefore issue the report within 10 working days of becoming aware that my obligation is triggered as I have not been able to establish that appropriate safety measure are in place for the reasons I detail below.

All relevant correspondence can be provided, but in summary:

1. I wrote to the National Trust on 29 January 2025 setting out my concerns following the Inquest and seeking further information on signage and any other incidents at the location.

2. By return letter received on 13 February 2025 I was advised that the wreck of the ship, SS Vina, was not the responsibility of National Trust (and they only provided the signage on shore), and that their understanding was that it was owned and managed by Trinity House.  Further, the land upon which the wreck sits is on long full-repairing lease to Natural England.

3. We therefore contacted Natural England who, by email of 12 March 2025, advised that there is no sign on the wreck, but that due to it being submerged at high tide, that would be impractical.  They stated however that the wreck is the property of Trinty House, who may consider a sign on the mast.

4. An email from Trinity House on 13 March 2025 stated however that they are not the legal owner of the wreck and had previously corresponded with the National Trust to advise them of this.

5. Upon seeking further clarification from the National Trust, they advised on 14 April 2025 that they had previously been advised that Trinity House had taken possession of the wreck of SS Vina.  Trinity House provided correspondence between the organisations to advise this was not the case.

6. Upon further enquiry with HM Coastguard to try and resolve this issue, we received an email from them dated 16 April 2025.  They have very helpfully tired to assist in resolving the question as to who is responsible for the wreck.  However, they advise that the wreck was privately owned when it was requisitioned in World War 2 by the MOD, but their records do not show who currently owns it but suggest that the Department for Transport may be able to assist with ownership.

7. I have therefore reached a point where I am unable to establish who may be the owner of this wreck and responsible for considering concerns over the lack of signage warning of risks.

The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)

1. I am concerned that, in light of the above, there is no safe system in place to ensure that an organisation is responsible for the management and safety of such shipwrecks which are accessible by members of the public.

2. With no clear system to ensure that the owners can be identified, there is no system to ensure that concerns can be raised with them when safety concerns arise.

3. That that wreckage does not have sufficient warnings at the location to alert members of the public, particularly those who are not familiar with the tidal waters, of the dangers present at the wreck.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 June 18, 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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:  Mr Mills’ family.

I have also sent it to:
The National Trust Trinity House Natural England
HM Coastguard
who may find it useful or of interest.

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 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 by the Chief Coroner.