Source · Prevention of Future Deaths

Christopher Taylor

Ref: 2015-0055 Date: 13 Feb 2015 Coroner: Maria Voisin Area: Avon Responses identified: 2 / 3 View PDF

The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life buoy stations.

Date 13 Feb 2015

56-day deadline 10 Apr 2015 est.

Responses identified 2 of 3

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ In this particular case it appears that the team in dispatch were not aware of the immediate incident which resulted in a in it being actioned by them: Staff need to be able to see at all times a screen which displays incoming incidents for them to be able to action in an appropriate manner; appreciate that Sainsburys were not represented at the inquest and do not have any evidence from them in relation to their plans for the bank next to the River Avon in Bath however would ask that they consider their responsibility as land owner along this stretch of river in question which falls within the high risk area. Specifically would ask that they liaise with Bath and North East Somerset Local Authority in relation to potentially the provision of a vandal proof life buoy station along that stretch of river:

Responses

2 respondents

Sainsburys Supermarkets Limited

13 Feb 2015 PDF

Action Taken

Sainsbury's met with local council and fire services, cleared vegetation to improve visibility and access, and maintains service level agreements. They also endorsed RoSPA's recommendation for user education and prioritize preventing falls into the river. (AI summary)

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Response by Sainsbury's Supermarkets Limited to Regulation 28 Report from HM Senior Coroner Mrs Maria Voisin arising from the Inquest into the death of Christopher David Taylor This response to the Regulation 28 Report arising from the death of Christopher David Taylor Report") is made on behalf of Sainsbury's Supermarkets Limited ("SSL") notwithstanding the report was addressed to Sainsburys Plc as SSL is the legal entity which operates the store adjacent to the River Avon in Bath_ SSL was not a Property Interested Person at the Inquest nor was it invited to be so and has not had the benefit of hearing the evidence given in the course of that Inquest: SSL has been provided with a transcript of the Prevention of Further Deaths Hearing in relation to the deaths of not only Christopher Taylor but also Samuel Amin which took place before HM Senior Coroner Maria Voisin on the 27 November 2014_ The Report issued by the Coroner by letter dated 13 February 2015 was received by SSL on 16 February 2015_ The Coroner's Matters of Concern in relation to SSL were expressed in the following terms: "Iappreciate that Sainsbury"s were not represented at the Inquest and | do not have any evidence from them in relation to their plans for the bank next to the River Avon in Bath; however would ask that they consider their responsibility as land owner along this stretch of river in question which falls within the high risk area. Specifically would ask that liaise with Bath and North East Somerset Local Authority in relation to potentially the provision of a vandal proof life buoy station along that stretch of river' SSL's response to the Coroner's concerns have been addressed in the manner out below On 29 January 2015 (which of course precedes the issue of the Report) representatives of SSL met with, amongst others the Team Manager (Licensing and Environmental Protection) for Bath and North East Somerset Council ("the Council") and of Avon Fire and Rescue Services_ At that meeting there was a discussion of the concerns that had arisen from the evidence during the course of the Inquest and the subsequent evidence and representations made at the Hearing to Prevent Further Deaths on the 27 November 2014. The management of health and safety to the highest possible standards is a priority for SSL and that approach extends to matters of safety where we are able to work with others to enhance 44_30574629 'the they set public

public safety and address issues of concern that have been identified such as those in this case_ Accordingly SSL has continued to work with the Council and other interested stakeholders to address the concerns encapsulated in the Report: Following the meeting on 29 January it was agreed that SSL would look at putting waist height fencing along the upper carpark walkway area. It was decided that it would be more appropriate for the fencing to be positioned there rather than along the actual water's edge at the bottom of the (newly cleared) sloped bank because It was thought that putting the fencing at the pavementlcarpark level would encourage people to stay further away from the river bank: It was also considered that there was no need for the previously planted area to become accessible to passers-by_
10. The fencing to be put in place was waist height in accordance with RoSPA recommendations that full height fencing can inhibit effective rescue of casualties in the water who may have entered the river further up-stream_
11. Temporary Heras style fencing has been put in place and will remain until a final permanent fence has been erected. Planning permission for the permanent fence is awaited_
12. Appropriate signage has been erected on the temporary fencing in four [ocations and will also be attached to the permanent fencing: The signage is "bespoke in design in that it encompasses a hard hitting local message and was agreed with the Council at the meeting on 29 January 2015_
13. So far as life-saving buoys were concerned SSL had already replaced the damagedlmissing buoy referred to in evidence during the course of the Inquest A stock of spare floats is kept at the store as vandalism is, as recognised by the evidence given at the Inquest_ problem. The life buoys are checked weekly as part of the store manager's normal safety routine and hence any damage will be noted and dealt with promptly_ 14, There were discussions with the Council and Avon Fire and Rescue Service as to the provision of tamperIvandal proof buoys which are opened by callers to 999 given a code to access the buoys. SSL has concerns as to the suitabilitylpracticality of such equipment. Our concern is that as with any bespoke equipment there can be issues with maintenance and repair in the future and that the requirement to call 999 could lead to people unsuccessfully trying to access the buoy if they did not have a telephone andlor were in a state of panic_
15. SSL has in place service level agreements suitable to maintaining the sloped bank area in its current clearedlcut down state of vegetation in order to maintain the improved visibility and emergency access that has resulted from the clearance measures undertaken:
16. SSL will keep the measures outlined above under review and if it has any reason to call into question the validity andlor appropriateness of those measures will raise those concerns with the Council and Avon Fire and Rescue Service. Similarly SSL will continue to work with the Council and Avon Fire and Rescue Service and has made it to those organisations that should they have any future or 44_30574629 heavy being put plain

on-going concerns they should raise them with SSL who will engage with them to give those concerns proper and full consideration: 17 . Finally, SSL has noted and considered the recommendations contained within the RoSPA report referred to in the transcript of the Hearing to Prevent Further Deaths which took place before HM Senior Coroner Maria Voisin on the 27 November 2014_ In particular SSL endorses the recommendation that the principal method of managing risk in the vicinity of the river Avon is to educate users and potential users and SSL supports the efforts made by the Council and others in that respect In terms of the hierarchy of controls_ which is a fundamental principle of health and safety management; the provision of life saving equipment is a control of last resort. The to preventing further deaths is to prevent persons inadvertently falling into the river and the Councils programme of information and education is integral to that Sainsbury's Supermarkets Limited 29 April 2015 4A 30574629 key

Avon and Somerset Police Police / Law Enforcement

25 Mar 2015 PDF

Action Planned

Avon and Somerset Constabulary outlines changes to their communication services, including a new call scripting system with dynamic assessment capabilities to be adopted in April 2015. They have also established a consolidated Learning Board to drive forward lessons from events such as this. (AI summary)

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Dear Ms Voirin In the matter of the death of Christopher David Taylor thank you for your letter dated 13th February 2015 and formally acknowledge receipt ofyour report made under Regulation 28 immediately recognise the circumstances leading to Mr Taylor's tragic death are such to demand proper consideration is given as to how the risk of similar events re-occurring can be addressed. would like to assure you and, through you Mr Taylor'$ family, that on behalf of Avon & Somerset Constabulary we take the process of learning lessons very seriously in order to collectively better serve our community. In preparing this response have reviewed the written statements submitted on behalf of the Constabulary: Without equivocation, share your assessment that any delay, such as this where there is no explanation, should not happen. The actions /'ve outlined below are those that have been initiated since Mr Taylor' $ death and which consider address the risks that are at the heart of your report Communications In his written evidence to the Inquest, Inspectorl loutlined the phases through which a call such a5 this would have progressed at that time_ For your ease of reference however, Inspector linformed the Inquest that Force Service Centre ('FSC' ) was the 'primary of contact for all emergency [calls] that come into the Constabulary' Designed to 'offer a comprehensive service for the public contact the Police' , FSC takes 'on average 2500 to 3000 call per day' which is roughly one call every 25 ~ 30 seconds It is evident enough from the calls logs disclosed to the Inquest, that the call taker' $ actions were efficient in gathering relevant information and prompt in transferring the call on for dispatch_ As per Inspector statement, once the call has been 'taken' it is transferred to from FSC to Dispatch, which is sited in different locations away from FSC. The disparity between the call taker'$ actions and the period of approximately 5 minutes during which no recorded action appears to have been taken is the first area the Constabulary has sought to address. It appears to me the risks of calls to be 'dropped' will be significantly lessened with Call Handlers and Dispatchers located together. Thus, from April 2015 the Constabulary will commence with the co-location of Call Handlers and Dispatchers who will then work as one team under a single supervisor. The unification of the two aspects of Communications will better enable information to be shared, ensure clear accountability of decision making and promote holistic thinking: In terms of these events, consider point

that co-location with single supervision is to have the effect of minimising the risk of an undocumented recurring: Secondly, the Constabulary is introducing a new THRIVE (Threat; Harm, Risk, Investigation, Vulnerability, Engagement) call grading matrix, as is in use by other Forces nationally: The focus of this new grading matrix is to ensure deployment decision making is in line with threat; harm and risk In the context of this system should operate to ensure that decision making processes, such as that which lead to the decision to call the ambulance service, are prompted at stage_ Thirdly, and in order to best embed effective use of THRIVE, the Call Handling role has been re-written to require a greater range of skills and capacity, such as were in evidence in this case_ All new staff recruited into this role will be trained in accordance with the enhanced requirements_ Fourthly, and in addition to the revamping of the Call Handler role; we are investing in our staff in rolling out a comprehensive scheme of training for Call Handlers and Supervisors to enable the modifications to their respective roles to be supported by learning: Finally, and perhaps most fundamental to the redesigning of our communication services, April 2015 the Constabulary will adopt a new call scripting system which is designed with tags and alerts for the benefit of the Call Handler/Dispatch team'$ ability to dynamically and continually assess of needs/priority of any one call: If taken in isolation, none of the above steps comprehensively addresses the specific concern in your report that staff may not be able to 'see at all-times a screen which displays incoming incidents_ However, | hope you would share my view that when put into operation in concert with each other; the cumulative effect is such that staff no-longer rely solely upon visual access to any specific screen: Organisational Learning Though not as a direct result of these tragic events, would also wish to impress upon you the Constabulary' s renewal approach to Organisational Learning, for which am portfolio lead. From February 2015 the Constabulary' s approach to Organisational Learning has been refreshed with the establishing of one consolidated Learning Board, which Iead, with wide ranging terms of reference intended to capture and drive forward lessons from events such as this. To ensure the engine room for corporate learning and change remains fuelled, each separate portfolio within the Constabulary has its' own Learning Forum with a similarly wide remit to feed into the Learning Board: do not believe that in their own right, these steps outlined above will ensure prevention all such incidents having tragic conclusions: do however believe and commend to you however; that these steps represent the Constabulary's belief in learning and implementation of that learning drawn specifically on these events My hope is that once implemented we, as an organisation will be better placed to respond to incidents such as this, in a way that will greatly enhance the chances of a different outcome_

Report sections

Investigation and inquest

On 31s January 2014 commenced an investigation into the death of Christopher David TAYLOR, Aged 21. The investigation concluded at the end of the inquest on 16"h January 2015. The conclusion of the inquest was as follows Medical Cause of Death 1a) Drowning Conclusion Christopher Taylor died when he fell into the River Avon in Bath; he was unable to find a way out himself and despite the efforts of the emergency services at the scene he was not able to be rescued by them

Circumstances of the death

Christopher was a student at Bath University and on 22nd January he had been out drinking with friends. The evidence of a witness was that he heard Christopher calling for help from the river and he dialed 999 for the emergency services_ That call was created by the call handler at Avon and Somerset Constabulary at 04:10 hrs. on 23r January 2014_ That call required an immediate response so it was graded as immediate at 04:12 hrs call handler completed the call and transferred it to dispatch at 04.14 hrs_ A subsequent witness indicated that immediate incidents are clearly indicated on the screen with a red flashing outline_ This immediate incident would have been flashing in the supervisors screen from 04:12 hrs_ and in the dispatchers screen from 04.14 hrs. The Force Service Centre Supervisor called to ensure that the dispatch centre were aware of the incident as the call had not been accepted: This telephone call resulted in the call being accepted at 04:19 hrs with officers being dispatched at 04.20 hrs. There is no explanation for what happened during that 5 minute period. Officers were at the scene at 04.23 hrs when Christopher was still alive At 04.36 hrs. Christopher went under the water and all attempts to rescue him were unsuccessful. During the inquest it became clear that there were issues in relation to fencing along the River Avon and the fact that all life buoy ring stations that were checked had no life buoy ring_present as they had been vandalised The heard that Bath and North East Somerset together with the Fire Service have been working on developing a vandal proof life buoy station: also heard that the length of the River Avon is not owned in its entirety by Bath and North East Somerset and indeed the banks are owned by many different people and organisations. The area of the river bank where Christopher fell in is owned by Sainsburys and this is considered to be in a high risk area:

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

Similar PFD reports

Shared signals

Report details

Reference: 2015-0055
Date of report: 13 February 2015
Coroner: Maria Voisin
Coroner area: Avon

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Apr 2015 (estimated).

Sent to

Avon and Salisbury Constabulary

Bath and North East Somerset Local Authority

Sainsburys Plc

Part of a series

2 reports

2021-0175 0 responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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