Dwayne Thompson
PFD Report
Partially Responded
Ref: 2019-0055
Coroner's Concerns (AI summary)
Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals with learning disabilities.
View full coroner's concerns
The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim inlcool down in during the heat of the summer: It was unusual in having fence and majority of reservoirs were easily accessible by the public There was signage to warn of the risks of swimming in reservoirs. This signage being the was used across all reservoirs including those with open access t0 (hem: It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when were devised,
Responses
Action Planned
RoSPA intends to invite all Greater Manchester Local Authorities to a workshop to discuss findings from a City Centre review of drowning incidents and develop plans to prevent future incidents. (AI summary)
RoSPA intends to invite all Greater Manchester Local Authorities to a workshop to discuss findings from a City Centre review of drowning incidents and develop plans to prevent future incidents. (AI summary)
View full response
Dear HM Senior Coroner, RE Death of Mr Thompson on 28th June 2018, and report to prevent future deaths Thank you for the letter of 15th February 2019. This letter sets out the steps we have taken to date and our further action: Background The Royal Society for the Prevention of Accidents (RoSPA) is a charity in existence for over century, we are concered with the prevention of accidents across the full range of life, both in the UK and abroad: RoSPA has no regulatory role, or enforcement powers. In considering our response we held discussions with: The Health and Safety Executive; United Utilities as the duty holder at Audenshaw Reservoir; the Inland Waters Group, a national group of companies with duties for inland waters within the National Water Safety Forum; the National Fire Chiefs Council drowning prevention lead. The following responses that of RoSPA_ We have not visited the location in question and offer no commentary with respect to measures in place. Our actions are numbered to the structure of your letter: A future without drowning: the UK drowning prevention strategy RoSPA host and provide the secretariat to the National Water Safety Forum (NWSF), a collective network that includes landowners, rescue organisations and sporting bodies. In 2016 it published the UK's first national drowning prevention strategy: A future without drowning (1). Our drowning prevention activity, and those of the NWSF network, is aligned to towards this strategy. Of particular note to this response are the targets for Community risk plans, Awareness of risk, Swimming and water safety education. The Royal Society for the Prevention of Accldents comptny Umitad by gustantet reglsend In England -Ith Na 211415 INVESTORS Gold Regbstered olike RaSPA Houx 2B Culthorpa Ratd Edqbaston Blningham: 015 [RP IN PEOPLE Reguateted chaniv Mo 20702] are key
RoSPA 28 Calthorpe Road R SPA Diitengtiaga 815 IRP Kingdom T+44 (0)121 248 2000 accidents don't have to happen helparospa.com Patron: Her Majesty The Queen Risk management and warning signage for the public Under UK health and safety law, it is incumbent upon the duty holder to maintain a system which identifies and manages risks to those affected by the workplace. RoSPA would expect the drowning of a member of the public at a reservoir to be a foreseeable risk. The question of how this is subsequently managed, by law, rests with the duty holder. We publish specialist; collectively agreed guidance to assist with these decisions. Further; we have previously assisted Water UK in the production of their guidance for reservoir safety There is a range of opinions on the role and effectiveness of 'safety signage' in public settings as a strategy to reduce drowning. Signage at inland water settings has developed through risk assessment or custom and practice , rather than a specific duty in law to place them in these settings. RoSPA's view is that signage can be effective if applied as part of an overall set of measures, but is much secondary to interventions such as clear level footpaths or limited use of barriers at points to deflect falls. Our preferred approach is to offer an integrated set of messages i.e. on websitelmedia, targeted awareness campaigns and if needed specific advice on site. Action 1. We have recently updated our national guidance: Managing Safety at Inland Waters (2). This is our principal advice for duty holders, and it includes examples and approaches such as risk communication and identification of hazards. The latest edition was published December 2018, and it is our intention to contact all Local Authorities and known duty holders including reservoir companies to inform them of the updated advice before the end of 2019. Cold Water Shock: awareness of this principal risk factor RoSPA and other specialists in the drowning prevention community are strongly of the opinion that Cold Water Shock (CWS) is the principal danger to life for those that enter water quickly in the UK The extent of the danger is not understood well by the majority of the UK population: CWS is an involuntary physiological response that overwhelms a person's ability to control breathing and affects swimming performance. This creates a sense of panic and rapid breathing, which can lead to aspiration of water and ultimately start the drowning process, resulting in death or life-changing injury: The critical window is the first few minutes of entry, after which the person's body acclimatises to the temperature. We have previously funded research to better understand this event (3): The Royal Society for the Prevention of Accidents company Ilmited by guarantcc Mglstetd In England wnih No. 2J14J5 INVESTORS Rcglstcrd otticc RoSPA House. 28 Calthoipe Roed, Edgbaston Blningham. BIS IRP Gold Reglstcred Chartu No 20702] IN PEOPLE very key key
RoSPA 28 Calthorpe Road R SPA Uneaghagcoms IRP T;+44 (0)121 248 2000 accidents don't have to happen
helpirospa.com Patron: Her Majesty The Queen CWS can be stopped before it escalates into a drowning: In addition to warnings, education on practical steps such as Float First; Float To Live, and Swim Safe campaigns could save a life_ Action 2. Steps that raise awareness of this principal risk, and importantly why it is a risk at given location, will have a positive impact: It is our aim to include members of Water UK as group before the end of 2019 to this end. Autism as a risk factor There is published evidence that highlights an increased risk of drowning among younger children: We have searched our fatal drowning databases for incidents between 2007 - 2018 and found: eight drowning incidents involved persons with autism reported as a pre-existing condition; of these, two were children under 10-years-old, the remainder between 20-30 years-old; all were male. In the same period over 8000 people died due t0 drowning: Action 3. The impact of autism on non-fatal drownings is not known in the UK: We have commissioned an analysis of trauma data to better evidence a collective understanding of autism as a risk factor: This is expected to be ready for publication before the end of 2019. Action 4. We will support the fire services' and partners' efforts to develop and formalise a national education pack to help the water safety or general safety practitioner to understand autism better: At the time of drafting this response am not in receipt of an agreed publication date, but will confirm in writing by the end of July 2019. Community level plans Drowning is a complex event; its causes can be found in the wider community as much as the immediate location, for example swimming ability or infrastructure that requires improvement: In order to prevent the next drowning event, consideration of the community as a whole is needed. During 2018 we worked with The Manchester Water Safety Partnership to review drowning incidents within Manchester City Centre, and to develop a plan for the City Centre as a whole to stop the next drowning: This was presented to the Greater Manchester Mayor in November and launched in December (3): The review considered waterways within the city, and included land within Manchester and Salford Local Authorities. Over the study period we found 28 drownings within the City Centre: We identified a further 111 drownings across other Greater Manchester authorities, to the best of our knowledge, there are no equivalent plans in place. Action 5. It is our intention t0 invite all Greater Manchester Local Authorities to a workshopto consider the findings from the City Centre review and the above points_ The Royal Soclety for the Prevention of Accldents company Itmited by quatantet fegistered In Engund wth (a 211435 INVESTORS Rcgkstcred @tkc: RaSPA House; 28 Culthaipa Rocd, Edgbaston Bhmtngham 815 IRP IN PEOPLE Gold Reglstcted charlvKa; 20702] key
RoSPA 28 Calthorpe Road R SPA Bniteagtagdoms 1RP Klngdom T +44 (01121 248 2000 helporospacom accidents don't have to happen WMTospacoM Patron Her Majesty The Queen We were deeply saddened to hear of Mr Thompson'$ death: If it is considered helpful we would be willing to meet with Ms Thompson Thank you for the opportunity to respond
RoSPA 28 Calthorpe Road R SPA Diitengtiaga 815 IRP Kingdom T+44 (0)121 248 2000 accidents don't have to happen helparospa.com Patron: Her Majesty The Queen Risk management and warning signage for the public Under UK health and safety law, it is incumbent upon the duty holder to maintain a system which identifies and manages risks to those affected by the workplace. RoSPA would expect the drowning of a member of the public at a reservoir to be a foreseeable risk. The question of how this is subsequently managed, by law, rests with the duty holder. We publish specialist; collectively agreed guidance to assist with these decisions. Further; we have previously assisted Water UK in the production of their guidance for reservoir safety There is a range of opinions on the role and effectiveness of 'safety signage' in public settings as a strategy to reduce drowning. Signage at inland water settings has developed through risk assessment or custom and practice , rather than a specific duty in law to place them in these settings. RoSPA's view is that signage can be effective if applied as part of an overall set of measures, but is much secondary to interventions such as clear level footpaths or limited use of barriers at points to deflect falls. Our preferred approach is to offer an integrated set of messages i.e. on websitelmedia, targeted awareness campaigns and if needed specific advice on site. Action 1. We have recently updated our national guidance: Managing Safety at Inland Waters (2). This is our principal advice for duty holders, and it includes examples and approaches such as risk communication and identification of hazards. The latest edition was published December 2018, and it is our intention to contact all Local Authorities and known duty holders including reservoir companies to inform them of the updated advice before the end of 2019. Cold Water Shock: awareness of this principal risk factor RoSPA and other specialists in the drowning prevention community are strongly of the opinion that Cold Water Shock (CWS) is the principal danger to life for those that enter water quickly in the UK The extent of the danger is not understood well by the majority of the UK population: CWS is an involuntary physiological response that overwhelms a person's ability to control breathing and affects swimming performance. This creates a sense of panic and rapid breathing, which can lead to aspiration of water and ultimately start the drowning process, resulting in death or life-changing injury: The critical window is the first few minutes of entry, after which the person's body acclimatises to the temperature. We have previously funded research to better understand this event (3): The Royal Society for the Prevention of Accidents company Ilmited by guarantcc Mglstetd In England wnih No. 2J14J5 INVESTORS Rcglstcrd otticc RoSPA House. 28 Calthoipe Roed, Edgbaston Blningham. BIS IRP Gold Reglstcred Chartu No 20702] IN PEOPLE very key key
RoSPA 28 Calthorpe Road R SPA Uneaghagcoms IRP T;+44 (0)121 248 2000 accidents don't have to happen
helpirospa.com Patron: Her Majesty The Queen CWS can be stopped before it escalates into a drowning: In addition to warnings, education on practical steps such as Float First; Float To Live, and Swim Safe campaigns could save a life_ Action 2. Steps that raise awareness of this principal risk, and importantly why it is a risk at given location, will have a positive impact: It is our aim to include members of Water UK as group before the end of 2019 to this end. Autism as a risk factor There is published evidence that highlights an increased risk of drowning among younger children: We have searched our fatal drowning databases for incidents between 2007 - 2018 and found: eight drowning incidents involved persons with autism reported as a pre-existing condition; of these, two were children under 10-years-old, the remainder between 20-30 years-old; all were male. In the same period over 8000 people died due t0 drowning: Action 3. The impact of autism on non-fatal drownings is not known in the UK: We have commissioned an analysis of trauma data to better evidence a collective understanding of autism as a risk factor: This is expected to be ready for publication before the end of 2019. Action 4. We will support the fire services' and partners' efforts to develop and formalise a national education pack to help the water safety or general safety practitioner to understand autism better: At the time of drafting this response am not in receipt of an agreed publication date, but will confirm in writing by the end of July 2019. Community level plans Drowning is a complex event; its causes can be found in the wider community as much as the immediate location, for example swimming ability or infrastructure that requires improvement: In order to prevent the next drowning event, consideration of the community as a whole is needed. During 2018 we worked with The Manchester Water Safety Partnership to review drowning incidents within Manchester City Centre, and to develop a plan for the City Centre as a whole to stop the next drowning: This was presented to the Greater Manchester Mayor in November and launched in December (3): The review considered waterways within the city, and included land within Manchester and Salford Local Authorities. Over the study period we found 28 drownings within the City Centre: We identified a further 111 drownings across other Greater Manchester authorities, to the best of our knowledge, there are no equivalent plans in place. Action 5. It is our intention t0 invite all Greater Manchester Local Authorities to a workshopto consider the findings from the City Centre review and the above points_ The Royal Soclety for the Prevention of Accldents company Itmited by quatantet fegistered In Engund wth (a 211435 INVESTORS Rcgkstcred @tkc: RaSPA House; 28 Culthaipa Rocd, Edgbaston Bhmtngham 815 IRP IN PEOPLE Gold Reglstcted charlvKa; 20702] key
RoSPA 28 Calthorpe Road R SPA Bniteagtagdoms 1RP Klngdom T +44 (01121 248 2000 helporospacom accidents don't have to happen WMTospacoM Patron Her Majesty The Queen We were deeply saddened to hear of Mr Thompson'$ death: If it is considered helpful we would be willing to meet with Ms Thompson Thank you for the opportunity to respond
Sent To
- Health and Safety Executive
- Royal Society of Prevention of Accidents
Response Status
Linked responses
1 of 2
56-Day Deadline
1 Aug 2019
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
On 29th June 2018, commenced an investigation into the death of Dwayne Daniel Ryan Thompson. The investigation concluded on the 17th January 2019 and the conclusion was one of accidental death: The medical cause of death was Ia hypoxic brain injury;1b freshwater drowning On 28th June 2018 Dwayne Daniel Ryan Thompson went with friends to the Reservoir at Audenshaw: Whilst swimming he got into difficulties and went underwater. Emergency services recovered him from the water and transferred him to Tameside General Hospital. Resuscitation continued, He had suffered a catastrophic brain injury as a result of underwater. He died at Tameside General Hospital on 28th June 2018. CQRONER'S CONCERNS During the course of the inquest; the evidence revealed matters giving rise to concern: In my opinion, there is a risk that future deaths will occur unless action is taken: In the circumstances, it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows: The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim inlcool down in during the heat of the summer: It was unusual in having fence and majority of reservoirs were easily accessible by the public There was signage to warn of the risks of swimming in reservoirs. This signage being the was used across all reservoirs including those with open access t0 (hem: It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when were devised, ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report, namely by 12t April 2019. |, the coroner, may extend the period. response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mother of the deceased and United Utilities who may find it useful or of interest. am also under a to send the Chief Coroner a copy of response. The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send 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: Alison Mutch OBE HM Senior Coroner 15hh February 2019 they ' duty ' days Your duty your
Action Should Be Taken
In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action
Inquest Conclusion
The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim inlcool down in during the heat of the summer: It was unusual in having fence and majority of reservoirs were easily accessible by the public There was signage to warn of the risks of swimming in reservoirs. This signage being the was used across all reservoirs including those with open access t0 (hem: It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when were devised, ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report, namely by 12t April 2019. |, the coroner, may extend the period. response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mother of the deceased and United Utilities who may find it useful or of interest. am also under a to send the Chief Coroner a copy of response. The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send 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: Alison Mutch OBE HM Senior Coroner 15hh February 2019 they ' duty ' days Your duty your
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.