Joseph Abbess & Sunnah Khan: Prevention of Future Deaths Report

Child Death (from 2015)Other related deaths

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Date of report: 10/10/2024 

Ref: 2024-0538 

Deceased name: Sunnah Khan and Joseph Abbess 

Coroners name: Rachael Griffin 

Coroners Area: Dorset 

Category: Child Death (from 2015) | Other related deaths 

This report is being sent to: Department for Education 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. [REDACTED], Secretary of State for Education
1CORONER

I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset.
2CORONER’S LEGAL POWERS

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. 
3INVESTIGATION and INQUEST

On the 2nd June 2023, an investigation was commenced into the deaths of Sunnah Summayah Khan, born on the 11th January 2011 and Joseph Ian Abbess born on 22nd November 2005. 
 The investigation concluded at the end of the Inquest on the 4th October 2024.

The medical causes of death were:
Ia Drowning

The conclusion of both of the Inquests was accident
4CIRCUMSTANCES OF THE DEATH

On the 31st May 2023 both Sunnah, who was 12 years of age, and Joe, who was  17  years  of  age,  travelled  to  Bournemouth  to  spend  the  day  at Bournemouth East Beach. Sunnah had travelled with her family and Joe had travelled with his friends. Neither knew each other. At some point after 15.14 hours they, separately, entered the waters at the beach in the designated safer swim zone, where they remained. At approximately 15.45 hours an intense flash rip current occurred in the waters, and both became separated from those they were with in the water. At approximately 16.18 hours, Joe was seen in an unresponsive condition faced down in the water. He was recovered from the water straight away and despite attempts at resuscitation and a brief period of return of spontaneous circulation, his death was confirmed later that day. At approximately 16.45 hours, Sunnah was seen in an unresponsive condition faced down in the water at the shoreline. She was recovered from the water straight away and despite attempts at resuscitation, her death was confirmed later that day. 
5CORONER’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:   

1. During the inquest evidence was heard that:

i. As the Maritime and Coastguard Agency (the MCA) “Managing Beach Safety” document (found here) highlights, UK beaches are special places which attract millions of people every year to enjoy the beauty of the beach and create lifelong memories. Like every body of water there is an element of risk  unpredictability which can lead to fatalities through drowning.
 
ii. One of the ways to reduce fatalities through drowning is by warning and informing users the water of the potential dangers.  

iii. The National Water Safety Forum (NWSF) was formed in 2004 and is a UK-focused voluntary network working to reduce water- related deaths and associated harm. Members of the NWSF have undertaken a great deal of work to supplement the awareness of water  safety.  This  includes,  for  example,  work  by  the  Royal National Lifeboat Institution (the RNLI), the MCA and the Royal Lifeguarding  Safety  Society  (the  RLSS)  to  name  just  a  few organisations.  Despite  the  great  efforts  by  these  agencies, unfortunately this information is only available to those who have access  to  it,  whether  that  be  through  the  internet,  media campaigns or other resources.  

iv. Water safety is covered in the physical education part of the curriculum  at  primary  schools  in  the  UK  and  by  the  end  of primary school all children should be able to swim at least 25 metres and have an understanding of self-rescue and survival skills to undertake the practical element of this learning. 

v. Research, which was undertaken prior to the covid pandemic which began in March 2020, has shown that 1 in 4 children do not  get  access  to  this  education.  Further  since  the  covid pandemic  there  has  been  a  reduction  in  schools’  access  to swimming pools.  

vi. If children do not get access to this vital lifesaving education in school, there are concerns as to where this awareness will come from.  Some  will  receive  it  from  privately  funded  swimming lessons, however not every child is fortunate enough to have such lessons.  

vii. The RLSS and Sunnah and Joe’s mothers have been advocating for water safety to become part of the classroom part of the curriculum  as  opposed  to  the  physical  education  part  of the curriculum on the basis that if children cannot do the practical part of water safety, they will at least have access to water safety awareness and lifesaving skills in a classroom setting. 

viii. Members of the NWSF, for example, volunteer members of the RNLI, the MCA do go into schools to provide talks to children, however, this would not be provided at every school. Further, the RLSS and Swim England provide resources that can be used in schools to educate children about the risks and survival skills around water safety. Again, this is delivered on a voluntary basis and will not be provided in every school. 

2. I have concerns with regard to the following:

i. There are inherent dangers of using any form of water and it is crucial for people to have an awareness of these risks and how to manage  them  as  the  lack  of  awareness  could  lead  to  more deaths from drowning. 

ii. An ideal opportunity to warn and inform all members of the public would be through educating children of the risks. The lack of providing education to children around these risks through the national classroom curriculum could lead to future deaths.  
6ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.    
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, 5th December 2024. I, the coroner, may extend the 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. 
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

(1) Sunnah’s family
(2) Joe’s family
(3) Royal National Lifeboat Institution
(4) Maritime and Coastguard Agency on behalf of His Majesty’s Coastguard
(5) BCP Council
(6) South West Ambulance Service NHS Foundation Trust

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

I  have  also  sent  a  copy  of  this  report  to  the  following  persons  for  their awareness: 
 
a) The National Water Safety Forum
b) The Royal Lifeguarding Saving Society

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. 
9Dated 10 October 2024
Signed Rachael C Griffin