UK Inquiry Tracker

Graham Coombe

PFD Report All Responded Ref: 2023-0440

Date of Report 10 November 2023

Coroner Rachel Redman

Coroner Area East Sussex

Response Deadline ✓ from report 8 January 2024

Other related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 8 Jan 2024

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Response Status

Responses 1 of 1

56-Day Deadline 8 Jan 2024

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns

1. A locked 10 foot gate prevented the police from accessing the lower level of the pier. The security officer on the pier did not have the key. Evidence was heard that only the Manager of the pier and the maintenance worker are key holders, neither of whom were at the pier on 1st May 2022. I heard evidence from the Sussex Police that a key should be kept in a key safe on the pier with the code being notified to them so that access can be obtained when necessary.
2. The life saving ring was neither in an accessible or visible place. It was in a cupboard hidden behind a bench. These safety aids should be stored visibly and be easily accessible.
3. The rope attached to the life saving ring was too short (although its length was within the prescribed regulatory guidelines) so that the buoyancy aid did not reach the water when thrown. I am concerned that the rope was of an insufficient length for the aid to reach the water at low tide.
4. I am concerned that there should be more life saving rings on Eastbourne Pier. I heard evidence that there should be one on either side of the pier half way down and one at its end.

Responses

Eastbourne Pier

Response received

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Dear Ms Redman & Ms Bruce

Further to your Regulation 28 Report: Details of action taken The lock on the gate that gives access to the lower end of the pier has been replaced with a digital lock. The lock on the gate at the front entrance to the pier is also a digital lock. Sussex Police have been notified of the gate codes ref 519 of 17thNovember 2023 The Coastguard has been notified of the gate codes at 12:15 17thNovember 2023 no ref given ESF&R have been notified of the gate codes at 12:20 17thNovember 2023 ref Rosalie The codes are the same on both locks and are also known by the staff members at each of the leased units on the pier. There are two life saving rings half way down the pier and three at the end of the pier, of which two are at each side and one is kept at the fishing tackle/fishermen's shop. All rings are easily visible and accessible. The length of the ropes on the life saving rings has been increased to 50 metres. Regards

Albany Lions Hotel Boship Lions Farm Hotel Mansion Lions Hotel Eastbourne Pier Grand Parade Lower Dicker Grand Parade Grand Parade Eastbourne Hailsham Eastbourne Eastbourne East Sussex East Sussex East Sussex East Sussex BN214DJ BN27 4AT BN213YS BN213EL Tel: 01323 722788 Tel: 01323 844826 Tel: 01323 727411 Tel: 01323 748710 Fax: 01323 419373 Fax: 01323 843945 Fax: 01323 720665 Fax: 01323 748711 albany@lionhotels.co.uk boship@lionhotels.co.uk mansion@lionhotels.co.uk sales@eastbournepier.com

Report Sections

Investigation and Inquest

On 11 May 2022 I commenced an investigation into the death of Graham Ian COOMBE aged
56. The investigation concluded at the end of the inquest on 13 October 2023. The conclusion of the inquest was that: Mr G Coombe was seen sitting below Eastbourne Pier when at approximately 7.20pm on 1st May 2022 he was seen to fall in. It was possible that he was suffering from the effects of alcohol. Attempts were made to find a life saving ring on the pier and than climb over a high locked gate to access the lower pier to try to save Mr Coombes. The lifeboat arrived at 1950hrs and removed Mr Coombe to the beach were CPR was continued. Mr Coombe died on 4th May 2022 as a result of drowning.

Circumstances of the Death

On 1st May 2022 at approximately 7.20pm Mr Coombe was seen to enter the water and then could be heard calling for help by those on the lower level of Eastbourne Pier which is not open to the public. Police were called who tried to gain access to the lower level of the pier but were obstructed by a locked gate. Eventually police were able to climb over it and made their way down to the lower level. They asked for a life saving ring which was not easily accessible nor visible. When this was eventually located and taken to the pier's lower level it was thrown to Mr Coombe but the rope was too short to reach the water as the tide was going out. The life boat was called and on arrival rescued Mr Coombe from the sea and commenced CPR which was continued on the beach. He was later taken to Royal Sussex County Hospital Brighton where he died on 4th May 2022 as a result of drowning.