This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 24th of July 2016 I commenced an investigation into the death of GUSTAVO SILVA DA CRUZ. On 29th of July 2016 I opened an investigation into the death of MOHIT DUPAR. On 25th of August 2016 I opened investigations into the deaths of INTHUSHAN SRISKANTHARASA, GURUSHANTH SRITHAVARAJAH, KENUGEN SATHIYANATHAN, KOBIKANTHAN SATHIY...NATHAN and NITHARSAN RAVI. The investigations concluded at the inquest into all seven deaths on 30th June 2017. The conclusions of the inquests are summarised on the seven Record of Inquest forms, copies of each of which I have attached to this letter.
Circumstances of the death
On 24th of June 2016 Mr. Da Cruz and Mr. Dupar went into the sea at Camber Sands, Rye. Mr. Da Cruz was seen to be in difficulties and his body was later washed up on the shore. Mr. Dupar was seen to be in difficulties and was brought to the beach unconscious. He had suffered from hypoxic brain damage and died at Ashford Hospital, Kent on the 28th of July. The other five deceased were all part of a party of five young Sri Lankan men who travelled together to Camber to enjoy a day at the beach on 24th of August 2016. They all went into the sea at a time when the tide had started to come in. It is not known how well any of them could swim. It is thought that they were all on a sand bar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore that day, or found after the tide receded. The RNLI had recommended deploying lifeguards at the beach in 2013 but Rother District Council had not implemented that recommendation. It was accepted quite quickly after these deaths and lifeguards are now deployed. There was considerable evidence at the inquest on the question of whether that step, and others recommended, would have prevented any of the deaths. It should be noted that the length of the beach from which people can swim is about three miles and the distance between high water mark and low water mark is as much as a kilometre in some tides.
Coroner’s concerns
(a) 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.
(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? 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 Camber.
(c) Changes include:-
(i) possible climate change effects, (ii) differences in ethnic origins and language spoken by current visitors, (iii) 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, (iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
(e) There was pessimism expressed at the inquests that any measures could prevent most deaths, only reduce them. In those circumstances, should there be consideration by central government of taking powers to restrict public use, according to daily circumstances, of parts or all of certain beaches? Certainly a localised study, on a national model, should be carried out. I believe it has elsewhere in the world.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised4
Visitors’ language difficulties and lack of experience with the sea
Failure to maintain effective public communication about coastal safety
Lack of formal governance and control of coastal risk management
Insufficient education and awareness of coastal dangers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.26
Action
Use fatality data and root-cause analysis to update national, local and targeted drowning-prevention messaging, while developing improved data analysis and impact metrics.
Stated byRoyal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Provide and continue the Camber Sands lifeguard service, including face-to-face beach-safety information and literature, when requested and supported by the local authority.
Stated byRoyal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Deliver and expand education and awareness programmes for children and others about coastal and inland-water dangers through staff, volunteers and partner organisations.
Stated byRoyal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Identify at-risk groups, including people facing ethnic or language barriers, and determine effective ways to communicate safety messages to them.
Stated byRoyal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Deliver beach-safety communications through digital platforms, modern advertising and face-to-face methods, while monitoring effectiveness and coordinating resources with other organisations.
Stated byRoyal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Carry out free beach risk assessments for local authorities, landowners and beach operators to inform decisions about lifeguard provision and risk controls.
Stated byRoyal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Standardise safety-information campaigns within the National Water Safety Forum and make campaign resources readily available to beach and other managers.
Promote beach-safety best-practice examples through the Forum’s network, communications and conferences.
Stated byNational Water Safety ForumStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Review the leadership arrangements for promoting strategic risk assessments and plans across recreational activity organisations.
Stated byNational Water Safety ForumStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Use the Forum’s network to promote awareness of water risks and influence public behaviour.
Stated byNational Water Safety ForumStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Influence communities to complete community-level risk assessments and establish water safety plans.
Stated byNational Water Safety ForumStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Nominate coastguard officers as National Drowning Prevention Officers targeting high-risk activities including diving, motorboating and swimming.
Stated byMaritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Operate the Coastal Safety mini-website providing consolidated safety guidance for families and casual beach visitors.
Stated byMaritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Fund an independent review of national beach-safety risk management and drowning prevention, including international and cross-sector comparisons.
Stated byMaritime and Coastguard AgencyStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
Action
Work with the RNLI on coastal risk management through visits to landowners about local risks and targeted safety interventions.
Stated byMaritime and Coastguard AgencyStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Provide two megaphones for beach patrol warnings about sandbars and incoming tides.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Review and revise the Camber Sands Community Risk Assessment and Safety Plan with partner agencies.
Stated byRother District CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
Action
Compile a comprehensive Camber Sands report for the Audit and Standards Committee.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Investigate translating the visitor safety leaflet into relevant languages.
Stated byRother District CouncilStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Action
Disseminate visitor water-safety advice through leaflets and posters at Camber Sands car parks.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Publish the Camber Sands report and invite committee debate on further actions to meet council obligations.
Stated byRother District CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
Action
Update and install safety signage in line with the new lifeguard provision.
Stated byRother District CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
Action
Operate two electronic dot-matrix signs at main beach access points with variable and multilingual messaging options.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
Action
Assist formation of a Camber RNLI branch to support lifeguard funding and water-safety awareness.
Stated byRother District CouncilStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.12
Position
There are no enforcement powers concerning implementation of the RNLI’s beach risk-assessment recommendations.
Stated byRoyal National Lifeboat InstitutionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Those responsible for beaches must provide resources and implement the control measures identified by risk assessments.
Stated byRoyal National Lifeboat InstitutionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, landowners and beach owners or operators decide whether to implement advisory risk-assessment recommendations.
Stated byRoyal National Lifeboat InstitutionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Formal governance of beach-safety risk management cannot be examined on behalf of the nation.
Landowners are responsible for assessing and controlling risks, including providing identified lifeguard services, within their jurisdictions.
Stated byNational Water Safety ForumRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Forum lacks legal, regulatory and enforcement powers to impose statutory beach safety governance or risk management requirements.
Stated byNational Water Safety ForumOutside remitThe respondent said that this matter was outside its role or authority.
Position
Landowners, often local authorities, are responsible for assessing coastline and beach risks and determining appropriate safety interventions.
Stated byMaritime and Coastguard AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A centralised or government-led UK coastline risk-management process would be difficult to achieve; local assessments are considered more appropriate.
Stated byRother District CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.24
1
Share drowning-prevention findings with partner organisations and support their prevention work through national and local partnership activity.
Stated byRoyal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
2
Monitor weather with the Met Office and deliver weather-dependent safety messaging through media outlets to beach users.
Stated byRoyal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
3
Create evidence-based activity risk profiles to identify groups at risk from water-based activities.
Stated byRoyal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
4
Deliver and further develop safety messaging for groups identified through activity risk profiles, raising awareness and influencing behaviour.
Stated byRoyal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
5
Continue supporting Swim England and partners in reviewing school swimming to remove participation barriers.
Promote the National Drowning Prevention Strategy targets and track and report progress.
Stated byNational Water Safety ForumStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
10
Update and expand use of the WAID database to produce evidence supporting targeted drowning-prevention resources.
Stated byNational Water Safety ForumStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
11
Disseminate best-practice examples of recreational governing-body guidance and member codes.
Stated byNational Water Safety ForumStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
12
Review the target concerning understanding water-related self-harm.
Stated byNational Water Safety ForumStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
13
Publish a report on progress since publication of the National Drowning Prevention Strategy.
Stated byNational Water Safety ForumStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
14
Identify suitable funding sources for WAID database development.
Stated byNational Water Safety ForumStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023.
15
Review the resources required to contribute effectively to accident prevention.
Stated byMaritime and Coastguard AgencyStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
16
Develop and implement the MCA’s Drowning Prevention Strategy and implementation plan.
Stated byMaritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
17
Conduct an independent review of the MCA’s accident-prevention activity and benchmark it against comparable maritime countries.
Stated byMaritime and Coastguard AgencyStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
18
Conduct the scheduled end-of-season beach-safety debrief.
Stated byRother District CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
19
Use an online facility for standardised weekly and incident beach-operation reporting and electronic retrieval.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
20
Provide seasonal RNLI lifeguarding at Camber Sands under an ongoing funded contract.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
21
Maintain joint working with Sussex Police through Operation Radcott for missing children, vulnerable people and public-order incidents.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
22
Maintain a year-round Deputy Coastal Officer post to strengthen beach-management continuity and resilience.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
23
Develop staff training and daily briefings using learning from the 2016 incidents.
Stated byRother District CouncilStated completedThe respondent said that this action was complete when they made their response on 27 March 2023.
24
Present Camber Sands learning to the Local Government Association Coastal Special Interest Group for wider council dissemination.
Stated byRother District CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 March 2023.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.8
1
Large-scale beach closures would be difficult or impossible to enforce and would require supporting legislation.
Stated byRoyal National Lifeboat InstitutionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
2
New lifeguard units can be established only with express permission from the relevant authority, owner or operator.
Stated byRoyal National Lifeboat InstitutionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
3
A lifeguard service cannot prevent incidents on UK beaches, although it significantly reduces risk for people swimming between the flags.
Existing site management and targeted closures can manage significant hazards without blanket restrictions on public access.
Stated byThe Royal Society For The Prevention Of AccidentsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
6
Finance limits the Forum’s ability to update and expand WAID, and it is seeking funding for that development work.
Stated byNational Water Safety ForumUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
7
MCA officials lack authority to restrict general beach access or prevent swimming.
Stated byMaritime and Coastguard AgencyOutside remitThe respondent said that this matter was outside its role or authority.
8
Restricting beach access at Camber would likely face public resistance, be disproportionate, burden operators and prove unworkable, except in exceptional circumstances.
Stated byRother District CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Information checked against the published report and official responses