Robert Cobbina · Prevention of Future Deaths report

An inquest into the death of Robert Cobbina was opened on 13 December 2018. The inquest was concluded at a hearing on 10 June 2019.
The conclusion of the inquest was misadventure.

Mr Cobbina left his home at c.0900 on 2 November 2018. His clothes were found by the River Thames at c.1030 by his wife. She called 999 and informed the control room that she believed he had gone in to the river. She was connected to the London Ambulance Service. Mr Cobbina was subsequently retrieved from the river that afternoon, and he was pronounced as life extinct at the shore. There was no evidence that in his particular circumstances Mr Cobbina would have been saved had he be found sooner.

1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently involve other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or .
2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference.
It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible, and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.