Inquest into three drownings on beaches in Cornwall

West Cornwall coroner Andrew Cox was speaking at the conclusion of the inquest into the deaths of three men that year following the easing of Covid restrictions.

He is to write a Preventing Future Deaths (PFD) letter to the cabinet office raising specific concerns that come out of the response to Covid as well as the wider concerns that remain unresolved after the events of Camber Sands in June 2017 when seven men died.

He will also write separately to the secretary of the Covid enquiry concerning the government’s lifting of restrictions without telling the RNLI as it had promised to do in a letter and not including lifeguards in the furlough scheme.

The easing of restrictions saw hundreds of thousands of members of the cooped up public flocking to Cornwall’s and the UK’s beaches, despite a massive national campaign by the RNLI warning people not to go into the water as there was no lifeguard cover.

On May 25, Michael Pender, 63, from St Merryn drowned after going into the sea of Treyarnon Beach near Padstow.

On June 25, 30-year-old Jan Klempar drowned at Porthcurno Beach after travelling down from the Midlands for a day trip with his family.

Then on August 20 Paul Mullen, 56, drowned at Church Cove, Gunwalloe whilst going to the aid of his son Ollie who had got into difficulty in the water. He was rescued but Mr Mullen died.

Mr Cox recorded death by misadventure on all three men.

Mr Cox heard that when lockdown started recruitment and training of lifeguards by the RNLI was forced to stop and it was an extremely challenging operating environment.

Medical advice changed and complex HSE guidance had to be considered for the employees and their ability to operate at various venues.

“On top of that there were difficulties with the furlough scheme introduced by the government,” said Mr Cox. “Some guards who were already trained and contracted but not then on a PAYE payroll were nevertheless paid by the RNLI on an ex-gratia basis.

“However, The vast majority of seasonal lifeguards however did not qualify for funding and inevitably this meant some had to source alternative employment.”

The RNLI and Cornwall Council managed to provide cover for 15 of its usual 56 beaches and the RNLI wrote to the government and Prime Minister asking for advance notice to be given to it ahead of any decision to relax national lockdown.

In reply they received a letter from the Minister for Aviation, Maritime and Security to the chief executive of the RNLI, John Payne.

In it she said: ‘Officials will ensure the RNLI is notified as far in advance as possible to mobilise your assets as appropriate’.”

“This did not happen,” said Mr Cox. “The RNLI were told of the relaxation of the lockdown the same time as the general public. Mr Payne made it clear that it would have been helpful to have had advance notice and I think there is a clear lesson here for the future.”

Mr Payne said the RNLI also had extreme difficulty getting PPI for its staff. In particular two orders of 15,000 masks were found to be unsuitable and an order of 100,000 masks only arrived in the nick of time ahead of lifeguarding services starting again on May 28.

The RNLI had to compete on the open market for the PPE and there is another lesson to be learned there, said Mr Cox.

A water safety message in was placed in the national media with the MCA costing £425,000, but the total RNLI media spend was £1.2M.

Additional signage had been displayed about no lifeguards being present and the public had been warned not to go into the water.

Mr Cox said an earlier test case had found that coastal landowners such as NT owe no statutory duty to prevent swimming, warn of the dangers of swimming or to mitigate the risk of drowning in the sea by the provision of lifeguarding equipment or services.

“The risk of drowning in the sea is ever present and obvious,” said Mr Cox “voluntarily accepted by everyone who enters the sea.”

The inquest heard Mr Pender knew the beach well and was aware that, as the restrictions imposed by national lockdown in the face of the Covid 19 pandemic were eased, lifeguard cover that had been present pre-pandemic had yet to start again.

“Mr Pender went into the sea to cool down and to urinate as public facilities were closed because of the pandemic, said Mr Cox. “He dived under series of waves and was pulled out of his depth.

An off-duty lifeguard Edward Kendall ran down the beach with his board and went into the sea but was unable to find him. When he was found he was unresponsive. He was taken to Padstow lifeboat station and confirmed dead.

Mr Klempar lived in the Midlands and had driven to Cornwall for a day trip following a night shift at the factory where he worked.

Additional signage had been placed at the beach but his partner originally told the inquest she did not see it.

But it was seen by a number of other witnesses including Luke Roberts, a member of the public, who had seen a number of signs as he made his way to the beach, a lifeguard who had been at the beach earlier and an attending police officer also saw it. “I find as fact signs were displayed,” said Mr Cox.

Mr Klempar got into difficulties whilst swimming in the sea. Members of the public pulled him from the sea but he could not be resuscitated.

The inquest heard that Paul Mullen had been coming to Cornwall on holiday with his family for over a decade and was familiar with the beach at Church Cove which in previous years had been lifeguarded. “There were no lifeguards in 2020,” said Mr Cox.

He said there was an unusually large swell that day which was caused by an approaching storm. Mr Mullen’s son Ollie got into difficulty in the sea and Mr Mullen went to his aid.

His son was pulled from the sea by helicopter but Mr Mullen was washed back to the beach unresponsive and was not able to be resuscitated.

Mr Cox said beach safety assessments at all three beaches to determine where lifeguards were deployed were ‘eminently sensible and entirely reasonable’.

The plan for the year had been to have three RNLI lifeguards at Treharne, two at Porthcurno and two at Church Cove, Gunwalloe. But on the date of each drowning there were no lifeguards at the beaches because of Covid lockdowns and a lack of lifeguards available. No flags were flying. 

Following the death of seven men on Camber Sands in 2017 a report was commissioned which found that the legal responsibility for the foreshore remains unclear, leaving those who manage the foreshore acting out of moral and social responsibility rather than any legal obligation.

Mr Cox said there are strict safety rules in public swimming pools but at sea, the one area where people are most likely to drown, no risk assessment takes place.

“This ‘ridiculous anomaly’ remains,” he said. “The lessons of Camber Sands have not been learnt. The stated aims to reduce drowning by half by 2026 seems likely to be missed.

“There has still, in my understanding, been no formal government response to the conclusions and recommendations of the review of legal responsibility for beach safety commissioned by the MCA from WDF (legal firm) which has been available since January 2019.

“It appears there is no formal government policy and no department responsibility for beach safety or drownings nationally.”

He said drownings total twice the number of those who die in fires annually.

He said the RNLI’s request to the government to resolve these current legal difficulties had not been actioned.

“Similarly the RNLI’s entirely sensible request to be provided with advance notice of government’s intention to relax lockdown was similarly not actioned,” he said.

“It seems to me we have a choice to make as a society. We either accept the unsatisfactory and illogical status quo with the high number of drownings which will inevitably continue. Or we turn our minds to the issues that have been identified and we make a concerted effort to resolve them.

“It’s not for me as coroner to make that decision, it is for me as coroner to raise the ongoing concerns that avoidable future deaths will continue unless those with the authority to do so take decisive action."

He said the lack of lifeguards on all beaches in Cornwall at that time was the result of two government decisions. The first was not to extend furlough to all the seasonal lifeguards recruited and trained by the RNLI when lockdown occurred. “I’m not suggesting had they done that all the difficulties would have been avoided,” he said.

Secondly the lack of advance notice given to the RNLI about the relaxation of lockdown and allowing people to travel to the beach again, despite an assurance from the government that it would happen.

“In my judgement, it was not due any lack of effort or organisation on the part of the RNLI, indeed to the contrary.” He said. “It is clear their employees moved mountains to have service on a reduced number of beaches only a fortnight after the learning of relaxation from lockdown.

“Those efforts continued thereafter and resulted in coverage of 80% of beaches by season’s end, rather than the predicted 30%. I have to say those efforts were matched by their counterparts in Cornwall Council.

“Three drownings in three months is a grim reality. What is daunting is that without the efforts of those concerned, the outcome could have been worse still.”

He said he found no neglect in the death of Mr Pender. He said he went into the sea of own free will, knowing the sea was dangerous and there were no lifeguards available.

He said he would write a Preventing future Deaths (PFD) to the cabinet office raising these specific concerns that come out of the response to Covid as well as the wider concerns that remain unresolved after the events of Camber Sands.

He will write separately to the secretary of the Covid enquiry about his concerns and it was up to the chair what they did with it.