Lawson Bond: Prevention of future deaths report

Child Death (from 2015)Other related deaths

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Date of report: 22/08/2023

Ref: 2023-0335

Deceased name: Lawson Bond

Coroner name: David Reid

Coroner Area: Worcestershire

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

This report is being sent to: Wychavon District Council

 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: [REDACTED], Chief Executive, Wychavon District Council, Civic Centre, Queen Elizabeth Drive, Pershore, Worcestershire WR10 1PT
1CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire.
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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3INVESTIGATION and INQUEST On 22 April 2022 I commenced an investigation and opened an inquest into the death of Lawson Bond, a child of 2½ years of age. The investigation concluded at the end of the inquest on 21 August 2023. The conclusion of the inquest was that Lawson died as the result of misadventure.
4CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Lawson come by his death?”, I recorded as follows: “On 28.3.22 Lawson Bond was attacked and mauled by an adult Rottweiler at his home in Egdon. The Rottweiler was in a field at the address, to which Lawson had gained access from his garden by climbing a gate and unhitching a security chain. He was taken to Worcestershire Royal Hospital, and then to Birmingham Children’s Hospital, where he died from his injuries on the morning of 30.3.22.” The Rottweiler which mauled Lawson was one of eight adult Rottweilers kept by Lawson’s grandmother [REDACTED]. For many years,                                           had been running a business breeding Rottweilers and advertising Rottweiler puppies for sale. She ought to have obtained a licence to carry out these activities, as per The Animal Welfare (Licensing of Activities Involving Animals) (England) Regulations 2018, but had never had one.
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)  In evidence to the inquest, [REDACTED], Principal Licensing Officer in the Licensing Team at Worcestershire Regulatory Services, agreed that the Licensing Team has a role in trying to identify unlicensed breeders, but stated that in this respect the Team is “intelligence-led”, i.e. that they will only act oninformation received or complaints made. Whilst the Team has an intelligence officer who will monitor websites, such monitoring will only take place in response to information received or a complaint made. The Team does not take a more pro-active approach generally, for example by searching websites and social media on a regular basis;

(2)    The inquest received evidence from staff at the Worcestershire Coroner’s Office, who had undertaken two separate internet searches looking for Rottweiler puppies for sale within the Worcestershire area. These searches were conducted on 9 June 2023 and 28 June 2023, and found recent adverts placed by [REDACTED on two separate websites ([REDACTED]), advertising Rottweiler puppies for sale. An identically worded advert was also found in the name of [REDACTED] accepted in evidence that this advert was placed on her behalf;

(3)    It might be thought that a regulatory authority would have less reason to be concerned about a scrupulous dog breeder, who applies and pays for a dog breeding licence, than about a dog breeder who ignores the licensing scheme. It is therefore concerning that Worcestershire Regulatory Services does not, at present, take a more pro-active approach in this regard, for example by monitoring websites for adverts placed by those selling puppies within its area. It would be quite possible to specify searches in such a way as to concentrate on breeds which might give a greater cause for concern in terms of safety.
 
For all of the above reasons, I am concerned that unless Regulatory Services within Wychavon District Council take action, there will remain a risk that unscrupulous unlicensed breeders will continue to offer puppies and dogs for sale within the Wychavon area, which present a heightened risk of danger to those who buy them and who come into contact with them.
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that you, as Chief Executive of Wychavon District Council, 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, namely by 13 November 2023. 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:
(a)   [REDACTED], Lawson’s mother;
(b)   [REDACTED], Lawson’s father;
(c)   [REDACTED], Lawson’s grandmother, who had Interested Person status for the purposes of the inquest.
 
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.
922 August 2023
David REID
HM Senior Coroner for Worcestershire