UK Inquiry Tracker

Clive Jones

PFD Report All Responded Ref: 2019-0217

Date of Report 30 April 2019

Coroner Ian Arrow

Coroner Area Plymouth, Torbay and South Devon

Response Deadline ✓ from report 26 June 2019

Other related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 26 Jun 2019

Coroner's Concerns (AI summary)

An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.

View full coroner's concerns

(1) At the Inquest MAIB Inspector Mr gave evidence of various procedures and policies_ Most important amongst these were the recommendations made by MAIB which were as set out in Section 5 of his report (and are annexed) that there be an independent review of the UK Search and Rescue operational capability and Her Majesty's Network Coastguard_ and Ition Jury lifting Flegg functionality: (2) To conduct a thorough review of Search and Rescue information technology systems to ensure a reliable network,

Responses

Department for Transport Central Government

8 Jun 2019

Action Taken
An independent review of the UK search and rescue (SAR) operational capability and functionality will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. A review of SAR information technology systems has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May. (AI summary)

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RECEIVED From the Secretary of State The Rt: Hon. Chris Grayling Department 8 JUN 2019 Great Minster House for Transport 33 Horseferry Road London HM CORONER SWIP 4DR lan W Arrow Tel: 0300 330 3000 Senior Coroner E-Mail; Plymouth; Torbay & South Devon Area Web site: WWW.gov Ukldft Derriford Park, Derriford Business Park Plymouth PL6 5QZ Is Thank you for your letter of in which you enclosed a Regulation 28 Report; following an inquest into the death of Clive Anthony Jones, which includes two concerns that relate to Her Majesty's Coastguard, part of the Maritime and Coastguard Agency (MCA): In relation to the first of your concerns about commissioning an independent review of the UK search and rescue (SAR) operational capability and functionality, understand that an independent review will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. The Terms of Reference have been agreed and the review will include looking at the SAR operational capability, including the implementation of actions identified by both the Maritime Accident Investigation Board (MAIB) and the Irish Coastguard; following the sinking of the SOLSTICE. The outcomes from this review will be captured in a completion meeting; which is on target to take place within the MAIB recommendation timeframe. have asked the MCA to write to you once that process is complete. The second concern recommendation, relating to conducting a thorough review of SAR information technology systems, has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May: am aware that a full review was conducted, and the improvements identified in the network have resulted in greater reliability and resilience throughout the UK trust this addresses the concerns raised in your letter. Lo L 631 C~) 1 Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT May,

Sent To

Department for Transport

Response Status

Linked responses 1 of 1

56-Day Deadline 26 Jun 2019

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

Following an Investigation an Inquest opened on 4 October 2017. The findings of the Inquest Hearing on 30 April 2019 at Plymouth Coroner's Court the following was determined: - The deceased was Clive Anthony Jones_ Medical Cause of Death was:- 1(a) Drowning 1(b) (c) Hypertensive Heart Disease The Conclusion of the was the death was as the result of an Accident.

Circumstances of the Death

On 26 September 2017 the deceased was on his own boat when the crew attempted to haul in an excessive weight within the net that had trawled. The net drum failed and accordingly an ad hoc arrangement was used which consisted of the net through higher block on to the transom but due to the weight it caused the vessel to list heavily to port_ The vessel was unstable and capsized: The deceased was trapped in the wheelhouse where he drowned, His body was later recovered by Navy divers _

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you as Secretary of State have the power to ensure the recommendations are followed. would ask you please to report to me firstly that the recommendations have been actioned and subsequently ask that you or your successor report to me once the reviews have been concluded and a report is produced provide me please with a copy and the relevant review report, shall be sharing both of these documents with the Chief Coroner.

Copies Sent To

30 April 2019 Signature M Arrow,Senior Coroner duty