Paul Alan Rogerson · Prevention of Future Deaths report

On 28.03.2011 I commenced an investigation into the death of Paul Alan Rogerson aged 26. The investigation concluded at the end of the inquest on 18.10.2011. The conclusion of the inquest was that the cause of Mr Rogerson’s death was Drowning and I recorded a verdict of Accidental Death.

On 26.03.2011 Mr Rogerson was out in York for a night out and had consumed several pints of beer. He jumped up onto a wall on Ouse Bridge at Kings Staith and attempted to walk along the wall but lost his footing and fell into the River Ouse. Police Officers and passers-by at the scene threw buoys on ropes into the water but he struggled to stay above the water and after several minutes he became submerged and did not resurface. His body was recovered by a police underwater search unit close to the point of entry several hours later.

(1) The position and protection of life buoys and throwing lines is inadequate. Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river. The integrity of this equipment is insufficiently protected from vandalism and the weather.

(2) There are no warning signs in place along the river bank within the city walls in York. Only one was found in the course of my enquiry, this being attached to a life buoy harness and being smaller than an A4 piece of paper. Public Houses near the river are not encouraged to display prominent warning signs in areas that their customers have access to the water.

(3) North Yorkshire Police Officers may require further training in current protocols for River Rescue and Water Safety.

(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue.

(5) North Yorkshire Police officers receive first aid training in CPR and wounds but Hypothermia is currently not covered.

(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.