Coroner raises safety concerns following a coasteering fatality

The inquest into the death of a client on a coasteering trip in Dorset in 2019 concluded recently. Following the inquest, the coroner sent a ‘Report to Prevent Future Deaths’ to various organisations expressing safety concerns.

The coroner has expressed concerns about three areas of safety management on led coasteering sessions:

  1. problems created by a single guide/instructor working alone – can an emergency be managed if the guide/instructor is incapacitated or, as was the case in this incident, the guide/instructor must attend to an emergency with one client;
  2. access to means for summoning emergency assistance if needed;
  3. client awareness of the true nature of the activity and its physical demands and provider awareness of clients’ physical health and swimming ability.

Issues raised:

This incident highlights some key questions for coasteering safety management arrangements.

  1. How are clients made aware of the true nature and demands of an activity?
  2. How are instructors/guides made aware of the relevant health and fitness issues of the clients?
  3. How are ‘go or no-go’ decisions made? How should guides judge existing and expected conditions as appropriate to a particular group of clients?
  4. What happens if a lone guide is incapacitated for any reason? Can the group manage the situation? How do they know what to do? How does the provider decide the clients can do what needs to be done?
  5. If an assistant guide is deployed what are the minimum competencies required of them?
  6. How will emergency services be summoned if needed? If they can’t be called immediately how will the intervening time gap be managed in such a way that the group continues to be safely led?


The coroner’s comments in full and the report are available at the Courts and Tribunals Judiciary website.