Hemanta Rai

PFD Report Partially Responded Ref: 2022-0232
Date of Report 26 July 2022
Coroner Rachel Knight
Response Deadline ✓ from report 20 September 2022
2 of 5 responded · Over 2 years old
Response Status
Responses 2 of 5
56-Day Deadline 20 Sep 2022
Over 2 years old — no identified published response
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) There is no adequate signage to warn visitors of the risk of drowning by entering the water at Sgwd Gwladys.

(2) Existing signage in 'Waterfall Country' is overloaded with a variety of information, which although helpful for walking routes etc, is not explicit in warning of the real danger of death from entering the water.

(3) Any sign(s) erected ought to be easily visible, in plain English and spell out the risk of death by drowning.

(4) It is very unclear who bears responsibility for this particular area, which borders 3 local authority areas, and falls within the National Park and NRW jurisdiction.
Responses
Brecon Beacons National Park
20 Sep 2022
Response received
View full response
Dear Sir Joint response by Brecon Beacons National Park Authority and Neath Port Talbot Council to the Regulation 28 Report (25 July 2022) in relation to the death by accident of Hemeta Kumar Rai on 16 August 2021.
1. Introduction
1.1.The Brecon Beacons National Park Authority and Neath Port Talbot Council wish to thank the Coroner for writing to their respective Chief Executives and Awdurdod Pan: Cenedlaethol Bannau Brycheiniog Brecon Beacons National ParxAuthority Plas y Ffynnoo. Ffordd Cambnvi.Aberhoriddu.fuv.ys. LD3 7HP P1as y Ffynnon, CambrianWiy. Brecon, Powys. LD3 7HP (~~l- H&I: (01874) 624437 Ffacs: (01874) 622574 Telephone:(01874) 624437 Fax: (01874) 622574 E-bost)'llholiadau@bannaubl)'che,niog.org E-ma.i· enqun,,@breconbeacons.org Safle ar ywe:www.bannaubrycheinog.org Website: www.brec~cons.org '"1tnu•u11 ""'•• 11 N•r•(JH&IU5 7he Aullon!r- r, Welsh 0t Ellflisl,

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--Ct) bringing to our attention the various matters of concern that were prompted by her investigation into the tragic death of Mr. Rai.
1.2. The Brecon Beacons National Park is an area which is designated for its special qualities consequently, signage is something we must consider very carefully in the context of a natural landscape.
1.3.Those concerns have been shared with and considered carefully by Brecon Beacons National Park Authority and Neath Port Talbot Council.
1.4. This report is our joint response on behalf of the Brecon Beacons National Park Authority and Neath Port Talbot Council to your Report to Prevent Future Deaths dated 25 July 2022, in accordance with the provisions of the Coroners and Justice Act 2009.
1.5. It should be noted that this response is based entirely on the Regulation 28 Report that was received. Despite further requests for information to the Coroner Officer no additional or specific information was provided.
2. Aims
2.1. Both Brecon Beacons National Park Authority and Neath Port Talbot Council express their deep regret and sorrow at the death of Mr Rai. We acknowledge the coroner's concerns and recognise the need to consider signage at the land we own and manage at the waterfall at Pontneathvaughan, Powys ('the Site'). This response is prepared to assure the Chief Coroner of our commitment to change, ongoing learning and improvement.
2.2.We will seek to respond to the key point of signage that has been raised by the Coroner's concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the Site by undertaking a signage review and implementing any necessary actions (see section Error! Reference source not found.). 2

3. Other parties
3.1.We are committed to working in partnership with each other and have extended the offer collaboration to other public body landowners and colleagues so that a joint approach can be pursued.
4. Immediate first steps
4.1. As a result of the concerns that the Coroner raised in her report, Brecon Beacons National Park Authority has commissioned an independent review of signage at the Site and a Site visit has been scheduled for 29th September 2022 which is to be led by the external health and safety consultant and attended by officers from Brecon Beacons National Park Authority, Neath Port Talbot Council and Natural Resources Wales.
5. Longer aims
5.1.As stated we are committed to working collaboratively with the other public body landowners and colleagues to improve our joint management of matters that affect visitors to the site. We hope that we can continue the dialogue to create a unified approach to health and safety matters within the National Park
5.2. In the interim, Brecon Beacons National Park Authority has commissioned a review of all signs within its high-volume visitor areas to ensure they are fit for purpose and are uniform in their design, content and application.
6. Policy Review
6.1. Brecon Beacons National Park Authority is in the process of reviewing the suite of health and safety policies which includes the policy covering the management of our sites and actions to be taken when health and safety concerns are received. Neath Port Talbot Council have also looked at the access way to such sites that are within its responsibility, to ensure matters are being considered appropriately. 3

I Ct)
7. Initial responses to the Coroner's Criticisms
7.1. It is important that we offer factual response to the Coroner's findings, both to acknowledge and to identify any failings and to correct any misperceptions which may be barriers to full learning.
7.2. The Coroner's key points are summarized here, and the full table can be found in her Regulation 28 Report. Coroner's Response Action already Action proposed Matters of completed Concern (1) There is no This area is not We have To review signage adequate signage within the instructed an within the National to warn visitors of ownership of independent Park and land in the risk of Brecon Beacons reviewer to the ownership of I drowning by National Park compile a I Neath Port Talbot entering the water Authority or Neath complete review of Council and at Sgwd Gwladys. Port Talbot signage within consider Council. implementing a areas within our public access uniform form of land ownership signage. (2) Existing We accept We have To review signage signage in additional signage instructed an and implement a 'Waterfall Country' can explicitly independent uniform form of is overloaded with address safety reviewer to advise signage. a variety of concerns on best practice information, which signs although helpful for walking routes etc., is not explicit in warning of the real danger of 4

Coroner's Matters of Concern Response Action already completed Action proposed death from entering the water. (3) Any sign(s) We agree with We have To review signage erected ought to using signs that instructed an and implement a be easily visible, in are clear to all independent uniform form of plain English and users regardless reviewer to advise signage. spell out the risk of of language. It on the formation death by drowning. should be noted that each authority must also comply with Welsh Language Standards which will have a bearing on any approach in signs that can be utilised and content of new signs (4) It is very It is accepted that Brecon Beacons To review signage unclear who bears land ownership is National Park and implement a responsibility for divided and can be Authority will install uniform form of this particular area, confusing user friendly signs signage which borders 3 delineating the local authority National Park area areas, and falls with a contact within the National detail regarding Park and NRW any queries. jurisdiction. 5
Neath Port Talbot Council
Response received
View full response
Dear Sirs, Please find attached a response to your Regulation 28 Notice in respect of the sad death of Hemanta Kumar Rai. This response has been prepared jointly with Brecon Beacons National Park Authority whom the Neath Port Talbot Council is presently working with to consider the issues raised in your Notice.
Action Should Be Taken
Coroner's Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1 JW
Report Sections
Circumstances of the Death
Hemanta Kumar Rai was aged 28 when he was visiting South Wales on holiday in the summer of 2021. On 16th August, together with a friend, he entered the area of a deep waterfall at Pontneathvaughan, Powys. A strong current pulled Hemanta, who was not a swimmer and was merely paddling, under the water towards the waterfall, and tragically, despite the efforts of friends and emergency services, he drowned.
Copies Sent To
of Mr Rai
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.