Dear Coroner

Regulation 28 Report to Prevent Future Deaths - Alex Edward CROOK who died on 7th September 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30th January 2025 concerning the death of Alex Edward Crook on 7th September 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deepest condolences to Alex’s family and loved ones. Wigan Council are keen to assure the family and the coroner that the concerns raised about signage and rescue equipment at Scotman’s Flash have been listened to and reflected upon.

Your Report raises concerns about the following:

1. Alex did not have statutory swimming lessons at key stage 1 or 2 and three schools in the Wigan area are still in breach of their statutory duty to deliver such lessons.
2. Signs have been erected as recently as 29th January 2025 at Scotman’s Flash, yet these do not contain the words ‘no unauthorised swimming’. It was agreed in evidence that if such signs were erected expeditiously close to the obvious entry points to the water, it may deter such use.

3. It was established in evidence that throwlines are the most effective life-saving equipment. It was noted that the proposal was to locate these away from obvious entry points. This would seem to be likely to make them less effective than if they were sited at the more obvious entry points. The need for such equipment, as with the signage is urgent.

Response to concerns raised in the Report

The Greater Manchester Water Safety Strategic Partnership is a collaborative, multi- agency project set up in response to the rising number of drowning fatalities in Greater Manchester. In 2021 and 2022 Greater Manchester Fire and Rescue Service (‘GMFRS’) attended more fatal water incidents than fatal fire incidents. The partnership involves stakeholders from all Greater Manchester boroughs and includes local authorities, Greater Manchester Police, North West Ambulance Service, local landowners, GMFRS as well as representatives from key national organisations such as the Royal Society for Prevention of Accidents, Royal National Lifeboat Institution and the Canal and River Trust. The partnership’s aim is to reduce the number of drowning incidents in Greater Manchester, the partnership has established a consistent approach and structure across all ten of the Greater Manchester Boroughs. The objective is to share best practice and expertise to ensure that a consistent message is delivered across the Manchester City region. There is a Water Safety partnership in all ten Greater Manchester boroughs, the local partnerships make local decisions on water safety, based on local knowledge of local water risk locations. The Wigan Water Safety Partnership (‘WWSP’) was established in 2021.

The WWSP met on 27th February 2025 and one of the actions from this meeting was that a letter was to be sent to all local authority aided primary schools in the Wigan borough in respect of the provision of swimming lessons. The duty to provide swimming lessons in primary schools as part of the National Curriculum is imposed on schools. Academies are not required to follow the National Curriculum, so therefore are not under a duty to provide swimming lessons. Local authorities are under a duty to promote high standards of education but the responsibility to ensure that the National Curriculum is provided lies with the individual schools. I can confirm that the Local Authority has written to all local authority aided schools within the Wigan Borough to remind them of the school’s obligations, as part of the National Curriculum, to provide swimming lessons for pupils. The correspondence outlined that this can be undertaken at Key Stage 1 or Key Stage 2 and aims to ensure that children can swim 25 metres, children can use a range of different swimming strokes efficiently and children can perform safe self-rescue. Schools receive funding as part of their PE funding to provide swimming lessons. It has been stressed within the correspondence that swimming lessons are a mandatory part of the curriculum.

I can confirm that the three schools in the Wigan area that had not provided swimming lessons at the time of the inquest have now all engaged and have booked swimming lessons. Furthermore, Mabs Cross Primary School, which is the primary school Alex attended have engaged in school swimming lessons with the Council for over 20 years and Alex’s class did engage in lessons when Alex was a pupil at the school. The WWSP also agreed an action to identify further support for swimming lessons for schools and young people. Common barriers to accessing swimming lessons tend to include class sizes, lack of year 6 mop up sessions, parental consent needed for attendance, transport costs and funding for high school swimming lessons, all of which are being considered by the WWSP in respect of a potential local pilot for free swimming lessons for young people within the borough.

Following the meeting of WWSP on 27th February 2025, a site visit was undertaken at Scotman’s Flash on Friday 28th February 2025, representatives from Wigan Council, Greater Manchester Police, GMFRS and the Canal and River Trust were in attendance.

Following the site inspection, all organisations present endorsed the Council’s decision (based on its latest risk assessment dated 6th December 2024) that the site should have five safety signs and three throwline boards. The Chair of the Greater Manchester Water Safety Strategic Partnership, who is also a Water Safety Development Officer attended the site inspection and was of the view that the proposals for Scotman’s Flash are proportionate and sufficient for a water risk location of the size and type as seen at Scotman’s Flash. There are only two locations in Greater Manchester with a higher density of water safety infrastructure, which are the Rochdale Canal in Manchester City centre and Salford Quays. Both locations have had many more fatal and non-fatal water incidents and have a much higher level of public access.

In respect of the signage, five signs have now been installed at Scotman’s Flash, which clearly and visibly warn the public of the dangers of deep water and cold-water shock. All viable approaches to Scotman’s Flash have now been covered by appropriate signage, these signs are much larger than previous signs. It was also agreed during the site inspection that supplementary prohibition signage including the wording “No unauthorised swimming or boating” will be added to the current signs. The prohibition signage has been produced and installed at Scotman’s Flash.

The location of throwlines was also considered at the site inspection on 28th February
2025. Throwlines are the most appropriate rescue equipment to install at the site, life buoys were considered, however this rescue equipment is best for fast flowing waters, which is not the case at Scotman’s Flash, rescue poles are partially exposed and therefore more vulnerable to vandalism. The plan below outlines the proposed location of the throwlines as of 28th February 2025.

It was agreed during the site inspection to amend the above plan to locate throwline “C” 100 metres further north, to better align it with likely swimming locations. It was acknowledged by the organisations present that Public Rescue Equipment (‘PRE’) is not a universal solution and cannot guarantee avoiding fatalities (only staying out of the water can avoid potential fatalities). For PRE to be useful the following must occur:

• The victim must be seen
• They must remain afloat until rescue takes place
• Appropriate rescue equipment must be to hand, and in operational condition

• An assessment of the area and its users should provide the basis for the use of PRE at any given site
• The other important criteria for siting PRE is a wider education strategy
• The rescuer must have the ability to effect the rescue
• The victim must be able to co-operate, i.e. grasp a rescue device.

An order has been placed for the throwlines and once received they will be installed at Scotman’s Flash.

I would also like to provide further assurances on the work that Wigan Council and the WWSP are undertaking around the Report to Prevent Future Deaths. Any Reports received where a death has occurred in/around an open body of water within the Wigan Borough will be taken to and discussed at the Water Safety Partnership meetings. This ensures that key learning and insights around events, such as the sad death of Alex, are shared across all agencies involved in the management and safety of open bodies of water and helps us to pay close attention to any emerging trends that may require further review and action. I can confirm that a risk review process with action plans is also being undertaken for Council water bodies across the Wigan borough, the level of works proposed will be dependent on the level of risk identified at each site. These risk assessments will be further quality reviewed by an expert GMFRS officer. Risk assessments, public engagement and education activities will continue to be considered by the WWSP. WWSP is due to meet again on 19th May 2025.

Thank you for bringing these important issues to the Council’s attention and please do not hesitate to contact me should you need any further information.