Dear Mr Ramsay,

Re: Regulation 28 report to Prevent Future Deaths DAVID CHIAKA EJIMOFOR

Thank you for your report to our Chief Executive regarding the death of David Chiaka Ejimofor and for setting out your concerns.

As the Chief Operating Officer at the RNLI, I am responsible for the lifeguarding service and as such I am responding on behalf of the Chief Executive.

As set out at the inquest, although the RNLI chooses to provide lifeguarding services, it has no legal duty to do so. Importantly, it cannot provide any service without the landowners or the occupier’s request or consent. It is entirely a matter for the landowner or occupier whether they ask and contract with the RNLI to provide a lifeguarding service.

However following the inquest, the RNLI is taking two actions:
1. Undertaking daily monitoring of people using:

i. Aberavon beach
ii. Little Beach (the beach to the left of the breakwater if looking out to sea)
iii. The breakwater

The monitoring started on Saturday 24 May 2025 and takes place between 10:00 and 19:30.

The purpose of the daily monitoring is to understand how many people are using Little Beach and, importantly, how many people are entering the water from the breakwater. This will allow the RNLI to make recommendations to its partner, Neath Port Talbot Council.

The monitoring will continue for the remainder of the 2025 Lifeguarding Season. Following completion of the season, a report will be prepared with recommendations.

2. We will work collaboratively with Neath Port Talbot Council and Association British Ports given the Coroner’s concerns.

In considering what action the RNLI will take, or recommend, we will take into account the wider issues which are set out below.

The Lifeguarding Challenge

As discussed at the inquest there is no statutory requirements for a landowner to contract for a beach lifeguard service. Even if it was a statutory requirement, it is improbable or more accurately impossible, that all beaches could be lifeguarded and even if they were it would be for defined seasons and defined times of day.

Further, the UK has:
• Over 7,000 miles of coastline (depending on how it is measured)
• 1,500 listed beaches
• 600 designated bathing waters, mostly beaches

Currently the RNLI is the largest provider of lifeguard services and in 2025 will patrol 249 sites on behalf of a range of clients, predominantly local authorities. There are fewer than 300 lifeguarded beaches across the UK.

It should be noted that the RNLI does not independently provide any lifeguard services that are not linked to clients and currently the RNLI does not have a contractual relationship with the owner of the breakwater.

Specific to jumping from structures into the water

Jumping from varying heights into water occurs from both natural and manmade structures all around the UK. In a controlled activity it is referred to as coasteering and as uncontrolled/unregulated activity it is referred to as tombstoning.

The National Water Safety Forum (NWSF) states that ‘It is important to recognise that tombstoning is an activity that has occurred around the coast for generations. Unfortunately, over recent years it has gained attention for the wrong reasons, with a number of people being killed or seriously injured. The title was adopted because of the way a person falls and plunges into deep water, in a similar way a stone would. Tombstoning is typically undertaken by individuals, with varying degrees of planning and formality attached. Quite often, the media will use the tag 'tombstoning' to describe a wide range of activities where people jump into the water from height.’

Restricting access or even universal provision of signage at all possible sites would be almost impossible and, in many locations, would prove to be highly unpopular.

The UK has:
• 100’s of miles of coastal paths
• 433 official harbours
• 62 seaside piers
• There are 100s of breakwaters of various designs, many that provide access to deeper water locations from the beach
• On usually a smaller scale, but often presenting the same management issues there are 1,000s of groynes and other sea defences, many that also provide access to deeper water locations from the beach

Restricting access

Options that restrict access such as fencing would be cost prohibitive and are likely to be defeated by individuals swimming or wading around the obstacle. Restricting access to aquatic locations is counter to the general principle of facilitating access to green and blue spaces.

The National Water Safety Forum (NWSF) has published principles for managing water related risks, the fundamentals of which include, that:
• No activity can be made completely risk-free.
• As far as possible, avoid restricting access to water spaces or facilities.
• As far as possible, avoid additional regulatory controls.

Lifeguards are normally deployed to facilitate bathing rather than preventing aquatic activities. If solely deployed to stop access it would be more appropriate to deploy a security guard or warden service.

Given the above challenges core swimming and self-rescue skills are important.

Core swimming and self-rescue skills

A key element of an individual’s safety in water is their swimming ability. The requirement in the UK is that all schools must provide swimming instruction either in key stage 1 (children 5-7 years old)) or key stage 2 (children 7-11 years old).

Pupils should be taught to:

• swim competently, confidently and proficiently over a distance of at least 25 metres
• use a range of strokes effectively [for example, front crawl, backstroke and breaststroke]
• perform safe self-rescue in different water-based situations

Unfortunately, not all children are achieving against the prescribed standard and a 2023-24 academic year report states that only 70% of Year 7 pupils (aged 11-12) can swim competently, confidently and proficiently over a distance of at least 25m.

Summary

The RNLI will progress with the two actions set out above.

Further the RNLI acknowledges that anyone can drown but no one should, and David’s death was a tragedy. The RNLI is a charity that works to end preventable drowning, and we will continue to influence, supervise and educate people and explain the risks and share safety knowledge with anyone going out to sea or to the coast.

Dear Sir Re: Regulation 28 Report: David Chiaka Ejimofor Associated British Ports wish to thank the Coroner for writing to our Chief Executive and bringing to our attention the various matters of concern that were prompted by his investigation into the tragic death of David Chiaka Ejimofor. Associated British Ports express their sympathy to the family of David Chiaka Ejimofor. I am responding on behalf of the Chief Executive and confirm that the Chief Executive has seen and approved this response. It should be noted that this response is based entirely on the Regulation 28 Report that was received. We acknowledge the Coroner's concerns and recommendations and are committed to working collaboratively with Neath Port Talbot Council (NPTC) and the Royal National Lifeboat Institution (RNLI). We will seek to respond to the point of deterrence measures (including signage and a limited height barrier) that has been raised by the Coroner's concerns and to identify any changes to signage, barriers and/or fencing at the breakwater to mitigate the risk of any future death by undertaking a signage, fencing and barrier review and implementing any necessary actions identified by such review. The review has commenced and will risk assess each option to ensure that by reducing one risk it does not create another. The initial review is anticipated to be concluded by the end of

` July 2025. The maintenance inspections of the breakwater will continue and Associated British Ports will consider the findings of each inspection to determine whether a further review of the deterrence measures is required. For a second successive year, Associated British Ports has deployed an additional security officer to monitor the whole of the Port Talbot Estate during the summer months. Associated British Ports have been informed via NPTC that the RNLI have been monitoring the breakwater. Associated British Ports are repeating this summer an awareness communication that has been run in previous summers warning of the dangers of water. The communication is posted on various media to include Instagram. Associated British Ports have no record of a lifeguard being located on the breakwater at times of higher risk. We trust that the information provided demonstrates Associated British Ports’ commitment to working to prevent future incidents in this area and to working collaboratively with other stakeholders.

Dear HM Senior Coroner for Swansea and Neath Port Talbot

Regulation 28 Report to Prevent Future Deaths – David Chiaka Ejimofor (Deceased)

This is Neath Port Talbot County Borough Council’s (NPTCBC) response to the report raised by HMAC Ramsay following the inquest into the tragic death of David Ejimofor by drowning having jumped into the Sea at the Small Beach, Aberavon from the breakwater owned by Associated British Ports (ABP).

Our thoughts continue to be with David’s family and friends following this incident.

NPTCBC has continued since the inquest hearing to engage in dialogue with the landowners, ABP, and our contracted specialists the Royal National Lifeboat Institution (RNLI). As the inquest was told, RNLI are continuing through this season to undertake intensive monitoring and assessment around the small beach area, including insofar as it can the breakwater, in order to identify the required provision for lifeguarding services. HM Senior Coroner for Swansea and Neath Port Talbot The Guildhall Swansea SA1 4PE

By email: and

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NPTCBC will continue its dialogue with RNLI in particular but also with ABP. NPTCBC will be led by RNLI’s recommendations in view of their nationally recognised expertise and will continue to address recommendations as far as is practicable within resource and budgetary constraints. ABP’s engagement with RNLI as to provision of services on the breakwater itself is beyond NPTCBC’s knowledge.

Turning to address the specific concerns raised by the Coroner:

There are no lifeguards stationed at the breakwater during high risk period in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it.

There is no duty in law on NPTCBC to provide lifeguards at beaches. Nonetheless, as HMAC is aware, NPTCBC engaged RNLI to assess the appropriate level of lifeguarding provision along the Aberavon seafront and upon its areas of ownership. It is not possible to have lifeguards stationed right across the beach at Aberavon, or at all beaches within the NPTCBC area, and so provision is targeted and public are reminded to look out for lifeguard provision and to, for instance, swim between the flags.

NPTCBC cannot police access to the breakwater, whether by lifeguard provision or otherwise. The breakwater is outside NPTCBC’s ownership.

There are ongoing discussions between NPTCBC, RNLI and ABP seeking to identify and where possible implement measures which would help to reduce risks to people who use the beach and those who choose and are able to access the breakwater and the sea from off the breakwater.

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As noted above, the RNLI is currently undertaking an exercise to monitor activity in the vicinity of the breakwater. These monitoring efforts and discussions are expected to continue across the summer 2025, to help inform a formal review of the Beach safety assessment and in turn a decision regarding lifeguard deployment for the 2026 summer season. Should it ultimately be determined that additional lifeguard coverage is necessary, NPTCBC’s intention would be to implement this provision during 2026 subject to the necessary funding being available.

NPTCBC will of course share assessment of the risks identified along the beach in RNLI’s assessment with APB.

Jumping from, and the water around, the breakwater is known to be dangerous

NPTCBC recognises that jumping from the breakwater into the sea is a dangerous activity. It is obviously so. NPTCBC cannot police access to third party owned land and does not own or exercise any control over the breakwater.

As previously outlined, discussions are ongoing regarding the potential implementation of additional water safety measures and interventions in the vicinity of the small beach to improve and support public understanding of hazards associated with this stretch of coastline, and where possible to provide methods of assistance for anyone who may get into difficulty.

The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months had been in place historically and was known to be effective at reducing the risk.

It remains NPTCBC’s position that lifeguards have not been stationed at the breakwater for well over a decade, with no evidence to suggest the risk has worsened over that period. David’s activity in accessing the breakwater and

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jumping into the sea was in any event outside of the hours at which lifeguard provision would have operated. Nevertheless, dialogue will continue between NPTCBC, RNLI and APB and once the outcome of the RNLI monitoring exercise is available it will of course be taken into account in identifying what, if any, further measures are appropriate to be taken.

Why lifeguards had been removed from the breakwater prior to David’s death and why that measure continues to be absent today.

As outlined at the inquest hearing, lifeguards were not regularly stationed at the breakwater but would occasionally pass there as part of a patrol. Lifeguard provision and arrangement for its implementation was changed over a decade ago, since when RNLI, as the national experts in lifeguard provision were engaged.

RNLI undertook its own beach safety assessment upon its engagement to provide services and since then has been provided with funding to implement the recommended level of services.

The current Beach safety assessments continue to recommend services along the Aberavon beach front area encouraging and instructing the public to swim at lifeguarded areas and during lifeguarded times. NPTCBC awaits the outcome of RNLI’s current monitoring and risk assessment period following which, if recommended, changes in service along the beachfront area will be implemented. If there are no changes implemented NPTCBC will continue to provide the lifeguarding provision in line with the current RNLI recommendations.

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Evidence that other deterrence measures put in place since David’s death are working effectively to reduce the risk.

Monitoring of the breakwater is ongoing. Once the analysis is complete, NPTCBC, in cooperation with RNLI and ABP, will be able to assess whether any additional deterrent measures are necessary to effectively reduce the identified level of risk still further.

NPTCBC remains firmly committed to working in close collaboration with RNLI and ABP to mitigate identified risks in this specific area. We continue to advance measures aimed at preventing any recurrence of incidents of this nature.

Following the conclusion of the ongoing monitoring and once determinations have been made, a further update will be provided to HM Senior Coroner for Swansea Neath and Port Talbot.