Skip to content
recurance

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

24 Jul 2017 · Coroner Alan Craze · East Sussex

The coroner's concerns

  1. 1. lack of formal governance or control of risk management

    “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.”
  2. 2. reliance on charity to manage safety

    “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 Cam”
  3. 3. climate change effects

    “possible climate change effects”
  4. 4. language barriers among visitors

    “differences in ethnic origins and language spoken by current visitors”
  5. 5. inadequate public communication

    “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”
  6. 6. lack of coastal safety education

    “improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea”

Responses

2023-0105-Response-from-RoSPA.pdf ↗· Health and Safety Executive

Stated action

“we suggest the following: (i) That the Government undertakes a review of the current system of risk management for the primary prevention of drowning harm, and how the UK compares to other leading nations such as Australia, New Zealand, Canada, Germany and Ireland, along with similar injury risk themes such as road traffic or fire risks.”

2023-0105-Response-from-Royal-National-Lifeboat-Institution-.pdf ↗· Royal National Lifeboat Institution

Stated action

“The RNLI draws on fatality data and its root cause analysis from the National Water Safety Forum's (NWSF) Water Incident Database (WAID). The evidence from that database (and from our own and open source data) helps inform the content of our annual national downing prevention campaign known as 'Respect the Water'. Learning also informs local campaigns and targeted messages to 'at risk' groups. This action has been underway for a number of years and also delivered through our membership of the NWSF”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error