Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi: Prevention of future deaths report

Other related deaths

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Date of report: 24/07/2017

Ref: 2023-0105

Deceased name: Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

Coroner name: Alan Craze

Coroner Area: East Sussex

Category: Other related deaths

This report is being sent to: The Secretary of State for Transport | Maritime and Coastguard Agency | Rother District Council | National Water Safety Forum | Royal Society for the Prevention of Accidents | Royal National Lifeboat Institution

The Secretary of State for Transport
The Health and Safety Executive
The Chairman of the National Water Safety Forum
The Operations Director RNLI
Birnberg Peirce Solicitors
Royal Society for the Prevention of Accidents
Local Government Association
The Chairman, Rother District Council
Maritime and Coastguard Agency
East Sussex Divisional Commander, Sussex Police
I am ALAN ROMILLY CRAZE, Senior Coroner, for the coroner area of East Sussex.
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 24th of July 2016 I commenced an investigation into the death of GUSTAVO SILVA DA CRUZ.
On 29th of July 2016 I opened an investigation into the death of MOHIT DUPAR.

The investigations concluded at the inquest into all seven deaths on 30th June 2017. The conclusions of the inquests are summarised on the seven Record of Inquest forms, copies of each I have attached to this letter.
On 24th of June 2016 Mr. Da Cruz and Mr. Dupar went into the sea at Camber Sands, Rye. Mr. Da Cruz was seen to be in difficulties and his body was later washed up on the shore. Mr. Dupar was seen to be in difficulties and was brought to the beach unconscious. He had suffered from hypoxic brain damage and died at Ashford Hospital, Kent on the 28th of July. The other five deceased were all part of a party of five young Sri Lankan men who travelled together to Camber to enjoy a day at the beach on 24t of August 2016. They all went into the sea at a time when the tide had started to come in. It is not known how well any of them could swim. It is thought that they were all on a sand bar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore that day, or found after the tide had receded. The RNLI had recommended deploying lifeguards at the beach in 2013 but Rother District Council had not implemented that recommendation. It was accepted quite quickly after these deaths and lifeguards are now deployed. There was considerable evidence at the inquest on the question of whether that step, and others recommended, would have prevented any of the deaths. It should be noted that the length of the beach from which people can swim is about three miles and the distance between high water mark and low water mark is as much as a kilometre in some tides.
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:
(a) There are possibly lessons in the circumstances of and the issues surrounding these deaths which may be of help to others on a national basis.

(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.

(c) Changes include:
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which
everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.

(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.

(e) There was pessimism expressed at the inquests that any measures could prevent most deaths, only reduce them. In those circumstances, should there be consideration by central government of taking powers to restrict public use, according to daily circumstances, of parts or all of certain beaches? Certainly a localised study, on a national model, should be carried out. I believe it has elsewhere in the world.
In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by the 18 September 2017. I, the Coroner, may extend this period.

Your 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.
I have sent a copy of my report to the Chief Coroner and all those persons or organisations names at the head of it.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a 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.
9Two expert witnesses gave evidence at the inquests and one of them, of Middlesex University, offered a paper raising 12 issues which I have attached to my Regulation 28 Report because it may assist discussion (Appendix A).
1024th July 2017 Alan R. Craze H.M. Senior Coroner East Sussex