Royal Society for the Prevention of Accidents
Other
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)
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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