Peter Dolan: Prevention of Future Deaths Report
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Date of report: 11/7/2024
Ref: 2024-0370
Deceased name: Peter Dolan
Coroner name: Alexander Frodsham
Coroner Area: Cheshire
Category: Other related deaths
This report is being sent to: Boat Safety Scheme
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Boat Safety Scheme | |
| CORONER I am Alexander FRODSHAM, Assistant Coroner for the coroner area of Cheshire | |
| CORONER’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. | |
| INVESTIGATION and INQUEST On 09 April 2024 I commenced an investigation into the death of Peter Richard DOLAN aged 63. The investigation concluded at the end of the inquest on 09 July 2024. The conclusion of the inquest was that: Accident | |
| CIRCUMSTANCES OF THE DEATH On 08/03/24 a fire took place on a canal boat on the Bridgewater Canal, Whitbarrow Road in Lymm. When the fire was extinguished a badly burnt body was recovered from inside the canal boat which was later identified as being Mr Dolan. Police attended and confirmed that there was no suspicious circumstances. Reason for inquest – unnatural death. | |
| CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Peter Dolan lived on a narrowboat which caught fire during the early hours of 8th March 2024. An investigation by Cheshire Fire and Rescue Service revealed that the likely ignition source was hot embers ejected from a solid fuel stove, and that there was no evidence of any smoke alarm having been fitted within the boat. The position of Peter’s body indicated that he was lying on a sofa when he died. It is presently a legal requirement of BSS that boats be fitted with carbon monoxide alarms, but there is no requirement that boats be fitted with smoke alarms (unless it is a hire boat for overnight accommodation). Any equivalent requirement for all other boats may reduce the likelihood of further fatalities arising from smoke inhalation and/or burns. | |
| ACTION SHOULD BE TAKEN 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. | |
| YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by September 04, 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. | |
| COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to [REDACTED] Cheshire Fire & Rescue Service who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. | |
| Dated: 11/07/2024 Alexander FRODSHAM Assistant Coroner for Cheshire |