Investigation and inquest
Following an Investigation an Inquest opened on 4 October 2017.
The findings of the Inquest Hearing on 30 April 2019 at Plymouth Coroner’s Court the following was determined:-
The deceased was Clive Anthony Jones.
Medical Cause of Death was:-
1(a) Drowning
1(b)
1(c)
II Hypertensive Heart Disease
The Conclusion of the Jury was the death was as the result of an Accident.
Circumstances of the death
On 26 September 2017 the deceased was on his own boat when the crew attempted to haul in an excessive weight within the net that had trawled. The net drum failed and accordingly an ad hoc arrangement was used which consisted of lifting the net through a higher block on to the transom but due to the weight it caused the vessel to list heavily to port. The vessel was unstable and capsized. The deceased was trapped in the wheelhouse where he drowned. His body was later recovered by Navy divers.
Coroner’s concerns
(1) At the Inquest MAIB Inspector Mr Flegg gave evidence of various procedures and policies. Most important amongst these were the recommendations made by MAIB which were set out in Section 5 of his report (and are annexed) that there be an independent review of the UK Search and Rescue operational capability and Her Majesty's Network Coastguard functionality.
(2) To conduct a thorough review of Search and Rescue information technology systems to ensure a reliable network.