the course of the inquest; the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory to report to you. The MATTER OF CONCERN is as follows. 1, There is evidence of a particularly high risk of death on this beach. There were seven deaths acknowledged by the Minister of Tourism between 2000 and 2015. Mr David Flett; son, has researched the deaths using the internet and press reports. His evidence was of finding 3 in 2009, 2 in 2014 (one may be at another beach) and 3 in 2015. In this period from 2009 there were reported to be 23 drownings over the whole island. If this data is correct it would appear that 30% of the nation'$ drownings occur on this beach_ reports that her taxi driver told her that locals called the beach as "The Graveyard". No data before 2009 was available. If there were no deaths prior to 2009 on this beach in the previous 9 years an explanation would seem to be needed to explain the sudden increase. Alternatively there may have been other unreported deaths prior to 2009, and thus the annual mortality rate may be very much higher than the Ministry suggested:
2. The Barbados National Conservation Commission documentary evidence was that this beach had three currents: undertows, lateral/littoral currents, shore drift and rip including flesh rips. The risks of these to swimmers were acknowledged and would seem to be on going and thus pertain both before 2009 and after 2015. Nevertheless, the report found no evidence that Mr Flett was in difficulty as a result of abnormal sea conditions, riptides or undercurrents, but the family see no other explanation of the sudden and unexpected drowning
3. The steps that the FCO has taken since this death is to produce general advice that warning and lifeguards Inay not be present on all beaches and that there may be unexpected currents. The advice about risks of swimming in general do not appear to draw the attention of holiday makers the risks acknowledged by the Barbados National Conservation Commission and evidenced by the family on this beach in particular_
4. The British tour operator now draws the attention of holiday makers to FCO advice and there is a general leaflet warning swimmers of dangers of swimming, precautions and of rip tides and listed lifeguard supervised beaches. But this advice remains general and does not inform holiday makers of dangers at particular beaches 5, The family submit and the coroner adopts in this report the suggestion that as ski runs are marked in colours of risk and that there is a range of difficulty and risk on different; designation of some a8 green, red and black would be a way of indicating relative risk to potential swimmers. During duty flong noting flags

6. The need for tourists to be aware of the geographic location of risks in booking holidays from the UK is one which the FCO is asked to consider: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I do not consider that the Regulation 28 regime is intended for application in Barbados, whose authorities are well aware of the risks and concerns raised by this death and have taken some steps including leafleting hotels about general risks. Thus the report is only copied to them for information However the coroner recognizes the interest and initiatives already taken in this matter by the FCO and believes that the Ministry will wish to consider whether can take any further actions to raise the awareness of these specific geographical risks. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by Tuesday 7u February 2017. I, the coroner, may extend the period, response must contain details of action taken O proposed to be taken, setting out the timetable for action. Otherwise You must explain why no action is proposed If you require any further information or assistance about the case; please contact the case officer, COPIES and PUBLICATION have sent & COpY of my report to the following Interested Persons: Comer Crawley Solicitors for the family Iam also sending copies for information to: Quality Manager at British Airways 5a1 Permanent Secretary Ministry of Tourism and International Transport St Michael Barbados Rt: Hon Richard L Sealy MP Minister of Tourism General Manager for Barbados National Conservation Commission The British High Commission in Bridgetown Iam also under a to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete Or redacted o 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: [DATE] [SIGNED BY GRONER] %-(2-IL they duty days Your duty