1Drll Royal National Lifeboat Institution West Quay Road, Poole, Dorset, BH1 5 1HZ Tel 0845122 6999 Fax 0845 1261999 Lifeboats Mr Alan Craze H.M. Senior Coroner for East Sussex 31 Station Road Bexhill-on-Sea East Sussex T40 1RG 13 September 2017 info@rnli.org.uk RNLl.org Patron: Her Majesty The Queen President HRH The Duke of Kent J(G RNII(fo:uhng) lld 01073377, RNII(Salt,) ltd2ZOZ2•«> RNU l£ntt1prbt)) Ltd 178-4500 Jlt~II <ompariu rt&hlttfd at Wu t Qtu y Road, Ponlt, Dor.set, 8H1S lttZ From: RNLI Chief Executive

Re: Kenugen SATHTHIYANATHAN (deceased)

Nitharsan RAVI (deceased)

Kobikanthan SATHTHIYANATHAN (deceased)

lnthushan SRISKANTHARASA (deceased)

Gurushanth SRITHAVARAJAH (deceased)

Gustavo SILVA DA CRUZ (deceased)

Mohit DUPAR (deceased)

Thank you for your letter dated 24 July 2017 under Rule 43 regarding the above matter. Background The RNLI declares its lifeboat response to the UK Government through the UK Search and Rescue Strategic Committee. This forms a part of our Concept of Operations and its Strategic Performance Standards. The lifeboat service that the RNLI provides enables the UK Government to meet its obligations under International Conventions for saving lives at sea. In our Concept of Operations, we also state that we will provide a lifeguard service on a seasonal basis, a prevention and education service along with a flood rescue capability. The RNLl's lifeguard service was first trialled in 2001. This trial was successful and its wider introduction started in 2002. Since then, a progressive rollout plan has been followed and this year 249 lifeguard units were operational around the UK during the summer season. We plan to continue that roll out plan as a part of our strategy to reduce drowning but we can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. This is a limitation on our ability to provide the service. In order to determine where lifeguard units should be provided and for what season length, the RNLI has developed a beach risk assessment service that is free to local authorities, land owners and beach owners/operators. However, the risk assessment and the outcome recommendations are purely advisory. It is for the local authority, land owner or beach owner/operator to then decide whether to implement the recommendations. There is no legal The RNLI is the charity that saves lives at sea Royal National lifeboat Institution, a charity registered in England and Wales (209603) and Scotland (SC037736). Registered charity number 20003326 in the Republic of Ireland

obligation for the RNLI to provide the risk assessment service and we do not have any enforcement powers concerning whether its recommendations are implemented. The current business plan sets out the RNLl's organisational strategic goal to reduce coastal fatalities by 50% by 2024 in the UK and Ireland. The RNLl's response to your concerns and our action points concerning them are as follows: a) There are possibly lessons learnt in the circumstances of and the issues surrounding these deaths which may be of help to others on a national basis. The RNLI agrees and understands the importance of learning lessons that can be of help to others on a national level. Action taken - The RNLI draws on fatality data and its root cause analysis from the National Water Safety Forum's (NWSF) Water Incident Database (WAID). The evidence from that database (and from our own and open source data) helps inform the content of our annual national downing prevention campaign known as 'Respect the Water'. Learning also informs local campaigns and targeted messages to 'at risk' groups. This action has been underway for a number of years and also delivered through our membership of the NWSF, our support of the National Drowning Prevention Strategy and our other partnership and influencing work at a national and local level. Specifically, our campaign and messages content is updated on a continuous review basis, with improved data collection/analysis and impact metrics under development. We will continue with this work in pursuit of our strategic goal to reduce accidental coastal drowning by 50% by 2024. We share our findings with partner organisations, encourage them to support our national messaging and we support their prevention work too. b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntary, structure be examined? While there is significant governance around the requirements for risk assessment under the Health and Safety at Work Act; what is unclear is the question of who has responsibility for beach safety or, more specifically, the in-water safety of beach users. There are no formal statutory requirements which prescribe required specific control measures. There is informal guidance in the form of ISO and British standards and publications such as 'Safety on Beaches' Clarification of the responsibility for safety on beaches has previously been identified as an issue that needs to be addressed. Greater clarity is needed about the duty of care owed by those responsible for beaches around our coastline and the RNLI would like government clarification concerning this.

Action taken - The RNLI is not in a position to examine the formal governance of beach safety risk management on behalf of the nation. We would welcome a review and believe that local authorities, landowners and beach owners/operators should have a more clearly defined obligation for the risk management of their beaches and to act on risk assessment outcomes. This, in our opinion would reduce the likelihood of accidental drowning occurring in the beach environment. Could perhaps the Marine (Maritime) and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? MCA enforcement powers relate to the Merchant Shipping Act and other legislation rather than for beach safety. The RNLI works closely with the MCA in promoting beach safety and drowning reduction efforts. If more resource for this effort was made available to the MCA then the RNLI would welcome that. Action taken -The RNLl's charitable activity to improve safety at Camber Sands has led to the provision of a 2017 lifeguard service there which we are able to provide next year and well into the future on the proviso that Rother District Council requests us to and supports our service. This service includes offering face to face beach safety information and literature as well. Other aspects of beach safety there are informed by the risk assessment and we believe it is for them to ensure the necessary resource is available to implement the identified risk control measures. Changes include:
1. Possible climate change effects;
2. Differences in ethnic origins and language spoken by current visitors;
3. Constant and fast changes in means of communication with the public, which was agreed to be crucial to the educative process;
4. Improvement; which is considered vital for education and awareness of costal dangers amongst children, and those who live far from the sea. Climate effect The evidence would suggest that annual fluctuations in weather and daily/weekly local weather conditions have a greater influence on beach safety than changes in climate change. Action taken - The RNLI monitors weather and works with the Met Office. Weather dependant messaging is already in use and we actively work with media outlets that are able to distribute weather dependent messages to beach users. Ethnic and language barrier considerations Action - The RNLI is already taking action to identify at risk groups, and the most effective means of communication of safety messages. At risk groups include ethnic groups and those that are likely to have language barriers.

Communication Action taken - The RNLI uses digital platform tools, modern advertising methods and face to face communication as methods to communicate with the beach going and wider public. We monitor the effectiveness of our communications and work with other organisations to make the best of combining our resources with others. Education and awareness of coastal dangers Evidence from countries that have introduced comprehensive programmes to improve the populations swimming ability demonstrates a significant reduction in the risk of drowning. Action taken - The RNLI and its partner organisations that support the National Drowning Prevention Strategy are committed to increasing education and awareness programmes. Particularly to children and their knowledge of coastal and inland water dangers. The RNLI is an advocate of this target in the National Drowning Prevention Strategy and supports the Schools Swimming Review recommendations that have been presented to Government this year. The RNLI has comprehensive educational and awareness programmes which are delivered through the RNLI staff and volunteer network and in partnership with others. This work will continue and grow in order to reduce the likelihood of accidental drowning, both inland and at the coast. The RNLI would also add that the way that people are using the sea appears to be changing, with more people engaging in a wider variety of water-based activities in, on and around the water. The RNLI has already created a series of evidence based 'activity risk profiles' to identify the at risk groups. Messaging to these groups is in progress, raising awareness and influencing behaviour change. This work will continue and develop further over the coming years. c) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed. Resource and monetary considerations will always be a factor in decision making. Action taken - The RNLI carries out the risk assessment of beaches free of charge. If the risk assessment outcomes lead to the RNLI providing a lifeguard service, then the RNLI will fund the provision of that service but with a contribution from the local authority, landowner or beach owner/operator to an agreed level of service. No direct overhead, training or equipment costs are passed on. We believe appropriate budgets for beach safety should be set by those responsible for their beach operation, in order to implement the necessary control measures identified by the risk assessment. d) There was pessimism expressed at the inquest that any measure could prevent most deaths, only reduce them. In those circumstances, should there be consideration by central government of taking powers to restrict public use, according to daily circumstances, of part or all of certain beaches? Certainly a localised study, on a national model, should be carried out. I believe it has elsewhere in the world.

Lifeguards already utilise a 'red flag' option which works effectively in informing swimmers of the dangers of entering the water. This procedure has a very high level of compliance. Closing a section of beach carries the risk of transferring the problem to other beaches; where no beach safety services may exist, and is therefore used sparingly. Large scale beach closures would be difficult, if not impossible, to enforce, and would require supporting legislation. It would be reasonable to question the appetite of law-makers to pass legislation that would restrict people from accessing the beach. Action taken - The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches. If lifeguards are present as a part of these control measures, the areas outside of the lifeguarded area must be given due consideration too. It is very important to recognise that a lifeguard service cannot be the only preventative measure on UK beaches. There is no absolute guarantee that control measures (such as lifeguarding) could prevent any particular incident. But it is crucial to recognise that lifeguards, where identified as a control measure, significantly reduces risk to those who 'swim between the flags'. Thank you for the opportunity to respond to your concerns. I believe the actions already underway through the Institution's work will lead to fewer drownings and serious incidents on the nation's beaches. I would like to stress though that it is imperative that risk assessments are undertaken and acted on, with those responsible for the implementation being clearly identified and held to account for inaction. Without this imperative being achieved, people will needlessly and tragically lose their lives.

Chief Executive

Dear Mr Craze I am writing to you further to your letter of 24 July 2017 written under the powers vested in you as Senior Coroner for East Sussex relating to the prevention of future deaths and the matters of concern raised by yourself with respect to the tragic loss of life at Camber Sands in July and August 2016. I understand the matters of concern you raise to be in summary:
• The opportunity for lessons learnt to be shared with others on a national basis
• A possible lack of formal risk management arrangements for UK beaches in the face of many changes: environmental, social and demographic
• Communications and educational issues
• The impact of resource availability on decision making for safety at the coast
• The possibility of restricting public use of UK beaches for safety reasons I have also taken note of the helpful summary of risk management issues raised by Professor Ball and attached to your report. You asked us to respond to your letter with details of action taken and proposed in response to your concerns. Further to the relevant inquests held in 2016 and 2017, you have received from us two reports setting out the policy and operational arrangements in place in respect of our beach management functions at Camber Sands, a number of ancillary reports and documents as well as the statements of and presented to the inquest in June 2017. The documents in question are:
1. Rother District Council Report and appendices to HM Coroner East Sussex 17 October 2016
2. Rother District Council Second report and appendices to HM Senior Coroner March 2017
3. Witness Statement of Anthony Leonard 23 June 2017
4. Witness Statement of Robert Cass June 2017
• Fax(01424)787879

-2­ I will not repeat this information here but will update you on actions taken since the inquests. You will already be aware that the Council took the decision to work with the RNLI for the provision of a seasonal lifeguarding service at Camber Sands from May 2017. Co-operation between the Council and RNLI has been very good and a successful service has been provided during the summer months. There have been a number of peak days at Camber Sands with capacity crowds. These busy days passed uneventfully with both the lifeguards and the Rother beach patrol dealing with lost children, first aid and advising and informing visitors. We have been working together to evolve and modify services and expect to make a number of small changes to the dates of service and deployment of lifeguards for next year. We have incorporated the contribution of £50,900 (index-linked) to the RNLI into our annual budget setting process and remain under contract to the RNLI for lifeguard services until December 2019. I note the RNLI have also been asked to respond to your report. We have continued our policy of providing a seasonal beach patrol complementing the lifeguard service and comprising nine staff in support of the Coastal Officers at Camber Sands. We have used the learning from the incidents of 2016 to develop the staff training provided at the beginning of the season and the daily briefings. We have purchased two megaphones for the use of the beach patrol to assist in moving people from sandbars on an incoming tide as required. Similarly we have maintained the effective joint working arrangement with Sussex Police known as Operation Radcott. As previously reported, this deals with missing/found children, vulnerable people and public order incidents. Sussex Police are currently investigating the use of drones for public safety purposes and we have given permission for them to fly them over RDC land. Our regular end of season debrief is scheduled for 9 October 2017. The Deputy Coastal Officer is now a year round post in support of and we expect the continuity and resilience offered by this appointment to strengthen the beach management function. The RNLI provided us with a signage audit carried out to their internationally recognised standards, involving the updating of existing safety signs in line with the new lifeguard provision. These have been commissioned and will be installed shortly when conditions permit. In addition, we have purchased and installed two electronic dot matrix signs positioned at the main access points to the beach which have shown variable messages through the summer, with the option for messages in other languages. A new leaflet setting out safety advice to visitors has been handed out to visitors at Camber. A copy is attached for information. A poster of this information is on display in the public conveniences at both car parks and is therefore seen by a large proportion of the visiting public. We are investigating the translation of this leaflet into relevant languages .
• Fax(01424)787879

-3­ We have improved the management reporting of our beach operations by developing an online facility for staff to submit both weekly and incident reports within a template that meets reporting standards and which are then stored electronically for later retrieval as necessary. With regard to your concern that information be shared with other relevant agencies, we are making a further presentation to the Local Government Association's Coastal Special Interest Group on 18 September 2017 in London when we will share our learning with other councils from around the UK coastline. We are of course willing to contribute to further awareness-raising and information-sharing initiatives. It is our intention to review and revise as necessary the Camber Sands Community Risk Assessment and Safety Plan with the assistance of the agencies represented on the Camber Beach and Water Safety Group. These agencies include RNLI, National Water Safety Forum, MCA/HM Coastguard, East Sussex Fire and Rescue Service, Sussex Police, South East Coast Ambulance service, Camber Parish Council and the LGA, as well as a number of local businesses. We are assisting the formation of a Camber branch of the RNLI in order to raise funds for the lifeguard service and raise awareness of water safety. Regarding the proposal for a more formal risk management process we feel quite strongly that a centralised or government-led approach to the issues of risk management around the extensive and varied coastline of the UK would be difficult to achieve. Our experience prompts us to agree with Professor Ball's finding that the task of risk assessment is "best performed by those with intimate knowledge of the location". Nonetheless, we would welcome any clarification that the Maritime and Coastguard Agency, especially HM Coastguard, is able to offer regarding support to local authorities in their role as beach operators. We are in agreement with you that the best approach to improving water safety around the coast (and elsewhere) lies in a more co-ordinated and better resourced approach to raising levels of awareness and education both of the public at large and of those with a professional or public service delivery role. We believe this risk based, proportionate and evidence-based approach accords with that of the Health and Safety Executive with which we have recently been in consultation. As a small local authority with limited resources we are committed to nonetheless do all we can to assist this educational effort. The East Sussex Fire and Rescue Service under the leadership of Chief Fire Officer Dawn Whittaker have been a significant support to this work at Camber and across the county. Specifically the ESFRS have conducted a water safety campaign in local schools and provided a team of safety advisors at Camber on busy days. Regarding the point about restricting access to part or all of certain beaches, we would advise that from our experience this would create a deal of public resistance were it to be introduced at Camber. There is an enormous amount of pleasure and wellbeing for people of all ages derived from year round access to the beach and sea in the Rother district. Taking this amenity away from the general public, even for short periods, may in our view be disproportionate, place new burdens on beach operators and in the end probably prove Fax(01424)787879

-4­ unworkable. Regarding the question of proportionality, from calculations of probability and risk we derive the finding that between the Council's formation in 197 4 and 2012 there will have been a minimum of 38 million visitors, and potentially up to 50 million, to Camber Sands with no drownings. We would of course implement a beach closure in exceptional circumstances to protect the public and when directed to do so for instance by the police. In addition we have used the 2012 byelaws to zone off the extreme sports area at Broomhill Sands for safety reasons. As part of our corporate governance and the requirements for accountability and scrutiny, officers of the council have compiled a comprehensive report to our Audit and Standards Committee. The report will be in the public domain a week before the committee meets on 27 September 2017 when Members of the Council will be invited to debate its contents and propose any further actions they deem necessary to meet our obligations at Camber Sands. A draft copy of the report is attached for your information. We would emphasise again that the tragic loss of life at Camber Sands on 24 July and 24 August 2016 is a matter of deep regret and we extend our sincerest sympathies to the bereaved families. I hope that the foregoing meets your requirements. Please do not hesitate to get in touch with myself or officers of the council to discuss these points or request further information.

Dear Mr Craze, Re: ARC/MAO/ Kenugen SATHTHIYANATHAN (deceased)

/Nitharsan RAVI (deceased)

/Kobikanthan SATHTHIYANATHAN (deceased)

/lnthushan SRISKANTHARASA (deceased)

/Gurushanth SRITHAVARAJAH (deceased)

/Gustavo SILVA DA CRUZ (deceased)

/Mohit DUPAR (deceased)

Thank you for your letter dated 24 July 2017, under rule 43 concerning the above matter. The National Water Safety Forum was formed in 2005 in response to a governmental enquiry into water safety. It is a voluntary organisation funded by its members and a grant from the Maritime and Coastguard Agency (MCA). Governance is provided through a coordinating group with the Royal Society for the Prevention of Accidents (RoSPA) fulfilling the role of secretariat. The Forum's aim is to develop, promote and share best practice in water safety and risk management to reduce accidental death, accidents and water related self-harm. To help achieve this it established a water accident and incident database, WAID and actively curates and maintains a variety of data sources populating it. The MCA, RoSPA and the RNLI support the administration of WAID through the provision of staff time. Each year a drowning report is published providing the UK's definitive record of drowning fatalities and causal analysis. This intelligence and further research commissioned by the Forum informed the development of the UK's first National Drowning Prevention Strategy published in February 2016 (www.nationalwatersafety.org. uk/strategy). With the support of UK Government a strategic target was set to reduce drowning in the UK by 50% by 2026. The Forum does not have any legal, regulatory or enforcement powers vested in it. In response to your letter of 24 July the NWSF co coordinating group has the following comments: Your matters of concern There are definitely lessons to be learned from this accident and the outcome of your inquest has proved very valuable indeed concerning that. National Waler Safety Forum - Working togetherfor water safety . '

Notwithstanding the depth and scope of your inquest investigation as a requirement of the legal system, the forum is not aware of any other formal or legal requirement for any organisation to investigate such incidents, in the way that, for instance, a road traffic accident or house fire fatal accidents are investigated. But with improvements to investigations the root causes and full range of lessons could be identified even more effectively. The forum would welcome any improvements that could be to be made into drowning fatality investigations. This would help ensure all lessons are identified, that can be taken account of by landowners when deciding what risk control measures should be put in place to prevent drowning in areas under their jurisdiction. Such a requirement could be of benefit to you and your colleagues as well as a source of evidence in the conduct of inquests. Governance and control of risk management The forum believes that governance and risk management requirements for beach safety are not satisfactory. There should be an increased onus and clarification for local authorities, beach owners and operators (generically referred to as 'landowners'), to ensure that they have in place a beach safety governance framework and current risk assessment for their area of responsibility and this should be a statutory obligation especially where their beach facilities are advertised as available to the public. The forum would support a review of the governance and risk management arrangements for beach safety in order to answer the question 'who has responsibility for beach safety and how is that responsibility met?' The answer should set out the legal and duty of care requirements. The forum believes that if landowners are obliged to comply with governance and risk management requirements then the likelihood of accidental drownings would decrease. The forum believes that this principle holds good for all water frontage with public access, be it inland and coastal, not just beaches. National Water Safety Forum action taken to prevent future deaths The publication of the National Drowning Prevention Strategy was a 'call to action' to those organisations, local authorities and government, that are in a position to make changes in order to reduce the risk of accidental drowning and water related self-harm. It's 5 targets set out how this can be achieved. The forum itself is actively promoting those targets and endeavouring to track and report on progress. We are due to publish a report covering progress since the strategy was published. For ease of reference the targets are set out below with an example comment on each, further details concerning progress are contained in our soon to be published annual report. Every child should have the opportunity to learn to swim and receive water safety education We support the 'schools swimming review' which has been presented to government. We would like the recommendations of this review to be accepted. Every community with water risks should have a community level risk assessment and water safety plan Through our network and direct with the Local Government Association we are influencing communities to carry out community level risk assessments and to have a water safety plan. There are some excellent of examples of best practice but these are far outweighed by those who have not given this matter the vital attention it deserves. National Waler Safely Forum - Worhing together for water safety

To better understand water related self-harm One of our coordinating group organisations had led on this target and the results will help the nation's interested organisations better understand water related self- harm to such an extent that we will soon be in a position to review this target and be more specific with it. Increase awareness of everyday risks in, on and around the water The forum's network has helped organisations work more closely together to promote awareness of the risks associated with water and influence behaviour change among the general public. All recreational activity organisations should have a clear strategic risk assessment and plans that addresses key risks The leadership of the forum's group, which will spearhead the promotion of this target, is being reviewed in preparation for action. To date we have spread best practice examples of recreational governing body organisations that have produced guidance and codes for their members. Additionally, the forum is intending to update and expand the use of the WAID database in order to produce even more compelling evidence that can be used by various organisations in order to target their resources to prevent drowning. A barrier to progress is finance; the forum is seeking to identify suitable sources of funding for this WAID development work. The forum's work is helping to raise awareness of beach safety and through our network, communication and conference channels we are promoting examples of best practice. Our real strength and greatest opportunity is to influence others and this is what we are doing. But in summary we would urge the chief coroner to call for clarification concerning 'who is responsible for beach safety' and 'how must that responsibility be met'. We believe by answering this question the landowner will be much clearer about their obligations to conduct and act on a risk assessment of the shoreline, shallow water and water based activity that takes place within their jurisdiction. For instance, if the risk assessment identifies a lifeguard unit as a control measure, they should be obliged to ensure that service is provided. This will be supported by a robust investigation requirement for when things go wrong. This change will save lives. Thank you for writing to the Forum and giving us the opportunity to comment and outline how our work and the National Drowning Prevention Strategy can contribute to helping to ensure the risk of these tragic accidental fatalities is reduced.

Chair of the National Water Safety Forum National Water Safety Forum - Working loge/her for waler safely

Dear Coroner Craze, Response to Rule 43 letter following the fatal incidents at Camber Sands in July and August 2016 Thank you for your letter of July 24, 2017. We were greatly saddened by last year's deaths at Camber Sands, and our thoughts remain with the families and friends of the young men who died. We welcome the opportunity to respond to the matters of concern that you set out. Background Drowning and other water-related harms in the UK account for, on average, 600 deaths annually. Of these cases, accidental drowning deaths number, on average, 400 per year - approximately one fatal drowning event every 22 hours. This is higher than the number of accidental fire deaths in the home or cycling deaths on the road , yet, historically, drowning prevention has not experienced similar awareness levels or support. The Royal Society for the Prevention of Accidents (RoSPA) is a national charity, currently marking its centenary, with no regulatory or enforcement powers. Our approach, within the existing structures for water safety, is to seek to influence, inform, coordinate activity and advise. A considerable amount of our resources are spent seeking to engage with government departments and local authorities to bring a coherent and focused approach to tackling the burden of drowning. The Royal Society for the Prevention of Accidents A company llmllod by guarantee reglste,od In England with No. 231435 I') INVESTORS IGold Rcgisl t!rcd office: RoSPA House, 28 Calthorpc Road, Edgbaston, Birmingham. 015 lRP ~_.di IN PEOPLE Reglste,ed Cha1lty No. 207823 X

Our efforts, with many of the named organisations in your letter, have focused upon a voluntarily collaboration within the National Water Safety Forum (NWSF), for which RoSPA provides the secretariat. Primarily, this has been to track and identify drowning events, produce information and guidance and recently to produce The UK national drowning prevention strategy 2016-2026, which was launched in February 2016 and which we understand was discussed during the Inquest. Of particular relevance to our response are the following strategy targets: Every community with risk to have a water safety plan and risk assessment Every child to have the opportunity to learn swimming and water safety skills Increase in awareness of the everyday risks associated with water. These three targets, agreed by members of the NWSF, are intended to address many of the immediate and underlying factors which we understand may have contributed to the loss of life at Camber Sands. The full strategy can be read at www.nationalwatersafety.org.uk/strategy/ and next month's RoSPA National Water Safety Conference in Bristol will discuss how to take forward the strategy's delivery. Matters of concern We have set out our response as per the points in your letter and here we address these in turn. (a) There are possibly lessons to be learnt in the circumstances of and the issues surrounding these deaths which may be ofhelp to others on a national basis. We are of the opinion that wider lessons can be learnt from the fatalities in July and August 2016 at Camber Sands. Indeed, learning from accidents, near misses and other incidents - irrespective of whether they were high-profile tragedies, such as those at Camber Sands, or smaller-scale events - is an important part of risk management and is an approach that RoSPA has championed for many years. In order to facilitate this learning, we believe a_ction is required nationally by Government, particularly the clarification of duties held primarily by local authorities. TheRoyal Society for the Prevention or Accidents /\ company llmlted by guarantee registered In England wllh No. 231435 r~1 INVESTORS jGold Rcgistc,cd offtcc: RoSPA Howe, 28 Calthorpc Road, Edgbaston. Blnningham, DIS l RP Registered Charily No. 207823 ~JIN PEOPLE

(b) There appears to be no formal governance or control ofrisk management requirements. Should the present, virtually voluntary, structure be examined? We believe that the prevention aspects of the water safety system would benefit from a review. Currently, there is ambiguity in terms of who has responsibility for managing water safety risks. The current prevention arrangements, particularly at a local level, are at best difficult to understand and interpret. At worst, arguably, these can inhibit possible duty holders from taking action to reduce risk. It is important to stress that we do not believe these concerns extend to emergency response arrangements, which are governed by the UK Search and Rescue (SAR) framework. Given that we believe that it is the prevention aspects of water safety that require the most scrutiny, we have focused our response upon these elements. Our understanding of the regulatory framework for England is as follows: Local Authorities as landowners, occupiers or managers of sites which the public use have duties towards staff under the Health and Safety At Work etc Act 1974 (HASW). Duties towards the public are created via Section 3 of HASW. In situations where there is an "undertaking" within the meaning of Section 3, the duty-holder is required to take "reasonably practicable" measures to address the risks created. To what extent an undertaking exists and what are reasonably practicable responses have developed in the courts. Breaches of these duties can give rise to criminal liability for organisations and individuals. The Health and Safety Executive (HSE) has set out a series of factors which it applies in determining enforcement action for Section 3 risks generally 1, and where natural features are a factor2. Occupiers or landowners have further duties towards visitors and trespassers on their sites under the Occupiers Liability Acts 1957 & 1984. Breaches of these duties give rise to civil liability which can result in court action and payment to make good. Statutory responsibilities for local public health services are set out in the Health and Social Care Act 2012. The associated outcomes framework establishes the national 1 http://www.hse.gov.uk/enforce/opalert.htm 2 http://www.hse.gov.uk/enforce/hswacl/docs/situational-examples.pdf The Royal Society for the Prevention of Accidents A company llmlled by gua,antee ieglstered In England with No. 231435 F) INVESTORS IGold Rcglslolod office, RoSPA House, 28 Callhorpc Road, Edgbaston, Ulrmlngham, DIS ! RP Registered Charily No. 207823 \___e' IN PEOPLE

priorities that local authorities are expected to work towards, alongside those set locally. Reductions in accidents to children and young people, along with road transport accidents, are monitored. There is no explicit mention of drowning harm in the national framework3. Thus action is left to the local decision-makers to determine if the issue needs consideration. The Civil Contingency Act 2004 sets out duties upon local authorities, fire and rescue services (FRS) and the Maritime and Coastguard Agency (MCA) as Category 1 responders to assess risk for areas for which they are responsible, and to work with Category 2 responders such as the HSE. Locally, such action manifests in the form of "integrated risk management plans" (IRMPs) through which some FRS, such as East Sussex, address drowning harm from both the prevention and emergency response aspect, as does the MCA nationally. The effect of the above statutory framework is that we have a national system that is well equipped to address drowning emergencies, after the fact, through the UK SAR framework. Yet, one that is comparably poor at identifying and preventing the causes of the fatalities. Further, the existing statutory framework has evolved in such a way that it can , arguably, inhibit possible duty-holders from acting to reduce water safety risks, or only take steps after a fatality in a reactive manner. The effect is that moral or reputational risk arguments become the dominant factors in the rationale to explore or address drowning risks proactively among duty-holders. As you correctly note in your letter, charities such as RoSPA and RNLI, or executive agencies such as the MCA and FRS, are then left to be the prime actors in reducing or managing these risks. Given the lack of clear duties, responsibilities and indicators, it is very difficult to identify and mitigate risks ahead of time. To address this, we suggest the following: (i) That the Government undertakes a review of the current system of risk management for the primary prevention of drowning harm, and how the UK compares to other leading nations such as Australia, New Zealand, Canada, Germany and Ireland, along with similar injury risk themes such as road traffic or fire risks. 3 http://www.phoutcomes.info/ The Royal Society for the Prevention of Accidents A company limlled by gua,antee ,eglsteied In £ngt•nd with No. 231435 r, INVESTORS IGold Rcglstc,cd office: RoSPh Howe, 28 Callhorpo Road, Edgbaston, Dlnnlngham. DI S IRP ~JIN PEOPLE Reglste,ed Chailly No. 207823

(ii) That the Government explores statutory options equivalent to those offered by The Road Traffic Act 1988. A duty upon local authorities to assess and develop measures to address water safety harm could be usefully explored.4 (iii) Clarification should be sought from the Camber Sands local HASW enforcing authority and the HSE on the issue of whether consideration was given to use of existing enforcement powers under HASW with regards to these incidents (iv) RoSPA is currently revising its water safety advice for owners and duty-holders of inland waters. Subject to resources, we will look to review the equivalent advice for coastal and beach environs by the end of 2018. (c) Changes include; (i) Possible climatic effects The findings of the Pitt Review in 2007 led to additional statutory powers and operational changes as to how the country adapts and responds to climatic risks, namely surface water flooding and coastal inundation events, such as those seen in the summer of 2004 at Boscastle. The local and national plans sit within civil contingencies frameworks as noted earlier. The water-related risks within IRMPs typically are infrequent events that affect multiple people, property and communities. As noted earlier, we believe these plans to be robust for the risks they are seeking to mitigate. However, they address different scenarios to those which account for the majority of fatal drowning events. Seasonal variations, such as periods of warmer weather and bank holidays, correlate with both fatal and non-fatal incidents. In our opinion, this is most likely due to the greater number of visits to open water spaces. RoSPA and members of the 4 Section 39 of the Road Traffic Act provides to the Secretary State for Transport and local authorities' powers to address road safety. Including; 3(a) must carry out studies into accidents arising out of the use of vehicles, and; 3(c) must, in the light of those studies, take such measures as appear to the authority to be appropriate to prevent such accidents. (http://www.legislation.gov.uk/ukpga/1988/52/section/39) The Royal Society for the Prevention of Accidents Acompany llmlled by guarantee registered In England with No. 231435 f') INVESTORS IGold Registered office: RoSPA Howe, 28 Calthorpc: Road, Edgbiuton, Birmingham, DlS I RP ~...,p' IN PEOPLE Registered Charity No. 207823

NWSF plan prevention activities to coincide with these periods, and step-up communication activity ahead of expected warm weather. Effective beach mangers regularly manage these peaks, and plan for these variations in service provision. (ii) Differences in ethnic origin and languages spoken by current visitors Understanding and planning for the variety of demands that any group of visitors present is a central competence for the effective beach manger. For example, kite surfers will want different facilities and features to dog walkers or families, and will require tailored approaches to minimise risks and disruption. It has been understood for some time that a// visitors pay little attention to physical safety information, at best spending seven seconds considering a signboard, for example, and, further, that text-based approaches are less well comprehended by all 5 groups. It is also well accepted that just providing information on hazards, does not necessarily affect behaviour. For example, a study on the information provided on rip currents at Bondi Beach, Australia, had no discernible positive, and sometimes a negative, effect upon subsequent safety decisions and behaviours.6 The risks of open-water - particularly temperature and cold water shock - are not well understood within the general population. We believe this to be a principal underlying factor in many drowning deaths. For this reason, raising general awareness is a central ambition within the drowning prevention strategy. Steps we have already taken include:
• The development of a UK and global standard for signs and symbols for water safety, addressing some of the limitations outlined above (ISO 20712). These have been designed in such a way that little or no country-specific language skills are required. Comprehension testing was a part of the development phase for these. The same symbols that are on now on British beaches can be found in the USA, France and Japan etc. 5 Operational research and comprehension testing towards the UK and ISO standard sign development. 6 Operational research between academia and Surf Lifesaving Australia to support the development of the ISO standard. TheRoyal Society for the Prevention of Accidents A company limited by guarantee registered In England with No. 23 t435 r) INVESTORS IGold Registered office: RoSPA House. 28 Calthorpc Road, Edgbaston, Dirmingham, 915 I RP \...,tF IN PEOPLE Registered Cha,Uy No. 207823

• The production of collective interpretation guides for the UK on "how to implement" these standards
• Improvements to the incident taxonomy for the WAID system, the UK's drowning database, have been developed. These include more detailed information on the person involved. The extent to which ethnicity and language skills are a factor in drowning has not been quantified in the UK. We are currently exploring the feasibility of studying these factors. However, it is our understanding that information on these are not routinely recorded at Inquest. We note, from your letter and media reports, that four of the drowning victims were undertaking education at college or university level. We will report back on the feasibility of undertaking, or progress towards, a study of the role of ethnicity and language skills as a contributory factor, either directly or in conjunction with other members of the NWSF by the end 2017. (iii) Constant and fast changes in communications with the public, which everyone at this inquest agreed to be crucial to the educative process We agree that being able to communicate using a variety of methods and approaches is important, and have agreed a target within the strategy to address this. Further, we agree that ensuring that organisations are up to date with this is a critical element of an effective beach management plan. As noted earlier, communications that lead to positive behaviours are difficult and expensive to execute at scale. There is already a significant amount of free or low-cost resources and insights available. The following is an overview of the opportunities at which the effective beach manager could engage with visitors/potential visitors and the types of resources available that could assist with this engagement:
• In schools, most notably at Key Stage 2 through swimming and water safety education, and aspects of the school PSHE framework. These are our only The Royal Society for the Prevention of Accidents A company limited by guaranlee reglslered In England wllh No. 231435 f") INVESTORS j Gold Rcglslcrod offfce: Ro5PA House, 28 Calthorpc Road, £dgbaslon, Birmingham, 815 l RP Reglslered Charity No, 207823 '4.i,~ IN PEOPLE

whole-populatio~ level measures available, and are covered in more detail against your following point
• When potential visitors are researching/choosing a venue/activity, including by "Googling" or using social media/websites such as Facebook, Twitter, lnstagram etc. Campaigns such as the RNLl's #RespectTheWater7 and HM Coastguard's information films8 have reached millions of people.
• Information and advice is reinforced en-route at service and train stations, on- the radio and billboards, in pubs and tourist accommodation.
• On arrival at the venue, such as the car park and other bottlenecks, and again at strategic points around the venue such as key footpath junctions. As mentioned earlier, we have standardised the information that can be provided at these points and provided free "how to" guides for managers. RoSPA also provides training and support to local authorities to help make rapid improvements and to develop integrated plans.
• Face-to-face information from a trusted person, such as a lifeguard, coastguard or fire officer. Within the NWSF, steps have been taken to standardise and collectively approach safety information campaigns, and to make readily available these resources to beach and other managers. For managers, events such as the RoSPA National Water Safety Conference, which takes place every 18 months to two years, and publications such as RoSPA's Leisure and Education Journal, which is produced quarterly, aim to provide useful policy updates and practical guidance to those who work within water safety. (iv) Improvement, considered vital, of education and awareness of coastal dangers amongst children and those who Jive far from the sea. As noted earlier, provision of swimming and water safety at Key Stage 2 is our only truly population-level water safety intervention available in England. Approximately 50 per cent of children reach the required standard, leaving millions of school-aged children without the requisite skills to improve survival chances. 7 www.respectthewater.com
• https://coastguardsafety.campaign.gov.uk/ The Royal Society for the Prevention of Accidents A company llmllod byguaianlee 1eglsterod In England with No. 23 143S I") INVESTORS IGold Registered office: RoSPA Hous~. 28 Calthorpc Road, Edgbaston, Birmingham, 01S tRP Reglsle,NI Charily No. 207823 ~__µI IN PEOPLE

We continue to support Swim England and partners in their review of school swimming, aimed at removing the barriers to participation 9. Primarily through the RoSPA National Safety Education Committee, we will continue to develop, champion and inform the PSHE framework, which covers topics of personal safety and resilience, and to call for PSHE to become a statutory requirement. (d) Resources and monetary considerations & Powers of the Coastguard We would welcome further resources to address the burden of drowning, irrespective of which governmental department or agency leads the initiative. RoSPA and members of the NWSF maintain a positive working relationship with the MCA, with support from the Secretary of State's for Transport's office. The question of further powers, we feel, would be best answered by a review. In order to address the drowning burden through national legislation and the extension of powers, consideration would need to be given to urban and inland areas not currently within the scope of the MCA. (e) There was pessimism expressed that any measure could prevent most deaths, only reduce them. In those circumstances should there be a consideration by central government of taking powers to restrict public use? We are very cautious of approaches that might result in the closure or restriction of access to current public spaces without a publicly available safety case being made. Significant landowners such as The National Trust or Canals and Rivers Trust successfully manage sites that have significant hazards to the public without noticeable impacts or blanket restrictions. It is also worth noting that landowners and local authorities already close certain areas during cliff collapse or flood events. Lifeguarded zones on beaches can be closed by use of the red flag system. Although these cannot provide an absolute guarantee, deaths within lifeguarded locations are extremely rare in the UK, and these are, in our opinion, the safest open water venues to swim. 9 http://www.swimming.org/ assets/Swim_England_ Curriculum_ Swimming_and_ Water_ Safety _Review_ Group _Report_2017. pdf The Royal Society for the Prevention of Accidents A company limited by 9ua1antee registered In England with No. 231435 t"') INVESTORS IGold Registered office: RoSPA House, 28 Calthorpc Road, Cdgbaston, Birmingham, D1S l RP IN PEOPLE Registered Charity No. 207823

lf any consideration is to be given to further regulatory powers that may have an effect in terms of restricting access; we would prefer a model akin to the Scandinavian countries or the Scottish access laws, establishing a balanced package of rights and responsibilities. Useful lessons from the Countryside Rights Of Way Act could be applied, in which occupier's liability was reduced and concurrent access rights created. We are happy for our response to be shared and published, and will report back to you on the actions we have taken.

) I
• From the Secretary ofState The Rt. Hon. Chris Grayling Department Great Minster House 33 Horseferry Road for Transport London SW1P4DR

Alan R Haze

Her Majesty's Senior Coroner for East Sussex Web site: www.gov.uk/dft 31 Station Road Bexhill-on-Sea East Sussex TN401RG Thank you for your letters of 24 July to me and the Maritime and Coastguard Agency, enclosing your Regulation 28 report to prevent further deaths. I am replying on behalf of the Maritime and Coastguard Agency, and Executive Agency of this Department, following discussions with them. Following the inquest held on 30 June 2017 and your investigations into the deaths of seven men at Camber Sands in the summer of 2016, you recommended that action should be taken to prevent the risk of future deaths of this nature and raised a number of matters of concern. I agree that lessons can be learned from this tragic incident and in this response, I set out some background and address each of your key points in turn. Background The MCA has a number of UK-wide functions, including search and rescue (SAR) and the surveying and inspection of ships. The MCA is a member of the National Water Safety Forum (NWSF) - which promotes accident prevention through education - and voluntarily contributes financially to the NWSF's running costs. In February 2016, the Minister of State for Transport at that time, , launched the NWSF's National Drowning Prevention Strategy; a copy is enclosed. This Strategy promotes a collaborative approach to accident prevention for stakeholders with an interest in water safety, both inland and on the coast. Turning to the key points raised in your letter, l would offer the following responses.

No formal governance or control of risk management There are more than 11,500 miles of coast around the United Kingdom, and the Government is opening coastal paths to support public health, fitness and wellbeing, whilst encouraging people to enjoy this country's coast and beaches. It is the responsibility of landowners (in many cases the local authority) who have a duty of care to assess the safety risks associated with their coastlines and beaches and to determine whether they need to put in place safety interventions. This may include safety signage and/or, where appropriate, professional lifeguarding services provided by the Royal National Lifeboat Institution (RNLI), the Royal Life Saving Society (RLSS) and other organisations. A current gap in risk management has been identified as a national issue and has been recognised through MCA's work with the NWSF. Target 2 of the Strategy states that: 'Every community with water safety risks should have a risk assessment and water safety plan in place'. Presently the risk management of water safety risks is conducted on an ad hoc basis and takes many different forms. To gain an understanding of the national situation, the MCA will fund an independent review of the current system of risk management pertaining to beach safety and the prevention of drowning. This will include research into how the UK compares to other leading nations such as Australia, New Zealand, Canada, Netherlands and Germany. The review will also compare other similar ris~ themes such as road traffic or fire harm, for the prevention of injury and will report by end of July 2018. MCA has enforcement powers akin to the Police and should be given resources to take a bigger role As you suggest in your findings, the MCA does have enforcement powers akin to the Police, but these only extend to matters contained within the Merchant Shipping Act and similar primary legislation and associated regulations. The MCA also has powers as the Receiver of Wreck for managing access to beaches to guard against looting and to protect wreck, salvage, stranded whales and similar wildlife. However, the MCA's officials have no powers to restrict access to beaches generally nor to prevent swimming. What is the MCA doing? As part of its response to the National Drowning Prevention Strategy, which aims to halve the number of accidental drownings by 2026, the MCA has developed its own Drowning Prevention Strategy with an implementation plan; again, a copy is enclosed.

In addition, we will review what resources we need to contribute effectively to accident prevention. Any additional identified resources will be built into the Agency's annual Business Plan, published each April. The Agency is already actively involved in some prevention work, regularly advocating safety messages and campaigns at targeted audiences. For example, in response to recent research indicating a growing public appetite for online guidance, the MCA launched this summer a Coastal Safety mini-website 1 which distils simple safety information in one place, for the benefit of families and casual beach visitors. Since 2007, the MCA has contributed coastguard incident data and provided staff resource to maintain and develop the NWSF Water Incident database (WAID) which records in detail, fatal water-related accidents. This data is used to analyse national drowning incident trends and to inform each member organisation's prevention strategies. The Forum is committed to continuing to expand, develop and draw on the database, which provides the evidence needed to monitor progress towards the National Drowning Prevention Strategy's vision and targets. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions. In addition, Her Majesty's Coastguard can call on its 3,500 volunteer Coastguard Rescue Officers based in local communities on the coast to provide engaging safety talks and demonstrations, and this is something MCA will be looking to do more of. The MCA and I are also keen to extend those opportunities to communities in our bigger cities so that people from urban backgrounds are better prepared for the risks they may encounter when they venture to the seaside. The Agency has recently nominated a number of coastguard officers to act as National Drowning Prevention Officers to target particular high - risk activities such as diving, motorboating and swimming. In summary, Her Majesty's Coastguard and the MCA are already engaged in work to support accident prevention messages. Working alongside the other organisations in the NWSF, the MCA is also actively exploring the scope for committing more of its existing resources to implementing its own and the national Drowning Prevention Strategy. 1 https://coastguardsafety.campaign.gov.uk/

The Agency will also conduct an independent review of its accident prevention activity and benchmark what it does against similar maritime countries in the world. Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT