Teacher drowned because emergency ladders in marina were too short
by TOM LAWRENCE · Mail OnlineA teacher fell into a marina and drowned because the emergency ladders to help her climb out were too short, an inquest heard.
Catherine Forbes slipped while walking back to her houseboat after a night out with friends on a cold evening last March, a coroner was told.
After falling into the cold water, the 57-year-old swam over to a nearby ladder but was unable to lift her legs high enough to reach the bottom step and pull herself up.
An inquest heard the bottom rung of the steps extended no more than 60cm beneath the surface of the water, meaning she would have had to be particularly strong to physically pull herself up.
Ms Forbes died on March 31 last year, after falling into Thames and Kennet Marina in Caversham, south Oxfordshire.
The teacher struggled for some time before succumbing to the cold and drowning, making her the third person to die in the Thames and Kennet Marina since 2016.
Senior coroner Darren Salter has raised 'industry wide' concerns to the The Yacht Harbour Association, over the measures in place to help those that fall into the water 'raise the alarm'.
Oxford Coroners' Court heard there is a risk that future deaths will occur unless action is taken.
In the hours preceding her death, the teacher was said to be drinking at the Marina bar with friends, it was reported.
The teacher left the bar just after 11pm and was said to be 'moderately intoxicated' whilst walking back to her houseboat alone in heavy rain and winds.
On her journey home, she slipped into the water, and despite attempts to rescue herself, she sadly drowned, Mr Salter said.
In a Prevention of Future Deaths report, the coroner said Ms Forbes was a 'strong swimmer'.
He said there was 'clear evidence' that she swam over to a nearby ladder and attempted to 'climb out', but in the 'unwitnessed' incident, was unsuccessful.
Mr Salter said the teacher had thrown her handbag from the water onto the pontoon, and there was marks on the toes of her boots indicative of her trying to get out.
It was heard the ladder she had attempted to scale was 1.5 metres in length and had three rungs in the water, with the bottom extending no more than 600mm beneath the surface.
'It would have required Ms Forbes to raise her legs up high and have the necessary strength to pull herself up,' the coroner said.
'It appears that, sadly, she was unable to do so before succumbing to the cold and drowning.'
Mr Salter ruled her death as an accident, but highlighted 'matters of concerns'.
'In my opinion there is a risk that future deaths will occur unless action is taken,' he said.
He said he had 'industry wide concerns' relating to the safety of Marina's.
'The particular concern is in relation to persons falling into the marina, on their own and unwitnessed, and what measures are in place to enable them to get out or raise the alarm,' he said in his report.
'Perhaps the main issue relates to sufficiently designed ladders, in terms of length and grip, but also their number, placement and visibility from the water at day or night (flags, fluorescent signage, lighting for example).
'It is not for me to make recommendations and I am not an expert of course on marina safety but it is my duty to raise concerns that reflect the evidence heard at inquest and the issues helpfully raised by Ms Forbes family.'
Mr Salter suggested flotation devices are placed onto the water surface and recommended alarm systems be installed which could be 'activated from the water'.
The coroner added: 'I am mindful that safety improvements have been made at the Thames and Kennet Marina, specifically in relation to risk assessment and ladders having been upgraded to 2m in length with a minimum of 1m beneath the water.
'This is welcomed, not least because Catherine Forbes was the third person to drown in similar circumstances at the marina since 2016.'
The coroner said despite the marina holding a 'Gold Anchor Award', it was 'not fully compliant' with The Yacht Harbour Association's Code of Practice in relation to the length of all ladders.
Mr Salter said he is aware the report is being reviewed so asked that the organisation is made aware of his recommendations.
He sent the report to the The Yacht Harbour Association Ltd, who have until January to respond.