The second day of the inquest into 55-year-old holidaymaker David Fell's death while swimming off the beach in July 2021 heard evidence that the RNLI's end of season report into water safety in 2019 included a warning that shifting sand bars were increasing the severity and frequency of rip tides on the coast, leading them to respond to two multiple-casualty 'near drowning' incidents that summer.
Mr Fell, a former professional rugby league player from Wigan, was staying at Haven's Reighton Sands holiday park two years later when his two teenage children -who were both saved by other beachgoers - got into difficulty.
Mr Fell had not been in the water originally but entered when his son and daughter were seen to get into difficulties. The girl was seriously injured and suffered an abdominal aortic rupture.
The RNLI lifeboat eventually retrieved Mr Fell's body.
However, assistant coroner for North Yorkshire Oliver Longstaff ruled that he had not drowned due to the lack of fluid found on his lungs, and instead considered it was likely he had suffered a cardiac arrest brought on by the stress of the situation, though this could not be conclusively proved.
Though a postmortem initially established that Mr Fell died from immersion in water, pathologist Dr David Scoones revised his opinion after hearing witness accounts on the first day of the inquest that Mr Fell had not been seen to struggle, shout for help and had never actually reached his children or their rescuers. He provided evidence that Mr Fell had a severely narrowed coronary artery that would have left him at increased risk of cardiac arrest.
The inquest was told that the RNLI and council jointly decided in 2019 that despite the higher risk of rip currents, it was 'not practical' to extend the lifeguarding coverage from Filey Bay to Reighton Gap on a permanent basis due to access issues.
Instead, lifeguards stationed full-time at Filey Bay would continue to patrol the 9km stretch of beach including the Gap in a vehicle and additional signage was installed along the path from the caravan park to Reighton Gap.
Mr Fell's wife Fiona had criticised Haven for not providing enough signage warning of rip tides on the first day of the hearing, and the company's regional health and safety manager Craig Valentine gave evidence about the measures the park operator takes to advise guests of the dangers.
Although Haven's land ownership ends at the foot of the path from the park to the beach, he said that since 2018 they have entered into a voluntary partnership with the RNLI with the purpose of educating customers about water safety. These included signs, leaflets distributed around the site facilities, park maps and a welcome email including links to the RNLI website and information on their 'Float to Live' campaign.
In 2019, following one of the multiple rescues at Filey Bay, there were further meetings with the RNLI and closer links were agreed. A poster was recommended for signs, and three were printed and erected on the path and beach cafe at Haven's expense.
Haven also stated that they were able to fund the installation of further signage at the end of the 2019 season and there were meetings with the council, RNLI and designers Contract Signs. By January 2020, the RNLI's site audit for Reighton Sands had not yet been completed, and the project was suspended in the first Covid lockdown.
In January 2021, Haven received 250 safety leaflets to be distributed in park reception areas and in February they contacted the RNLI to inquire about progress regarding the new signs. At this point the council agreed to erect them, and in May the contractors provided a quote and warned that there could be some delivery delays due to lockdown. By mid-July, there were still conversations regarding proofs, additional payment and other queries and the signs had not been received.
Scarborough Council's head of projects Christopher Bourne, whose remit includes tourist beach management, also gave evidence and confirmed that he was responsible for the lifeguarding contract with the RNLI and weekly inspections of lifesaving equipment, as well as the installation of warning signs on council land.
He visited Reighton Gap following David Fell's death and noted a lifebuoy, emergency telephone in working order and three 'Water is Unpredictable' signs on the route from the caravan park to the beach.
He confirmed that warning flags are only operational on beaches manned full-time by lifeguards, and that the three staff working on Filey Bay would conduct rotational patrols up to the Gap in their vehicle.
He added that following his team's review of the recommendations regarding rip tides in the 2019 RNLI report and decision not to proceed with setting up lifeguarding coverage at Reighton Gap, there had only been one incident, which was Mr Fell's death. He believed that the risks were able to be managed with signage.
Since the tragedy, the posters have been replaced by signs warning of the lack of a lifeguard presence, and a further risk assessment of Reighton Gap has been commissioned.
Recording a narrative conclusion, Mr Longstaff said: "This was a tragedy for the Fell family. The members of the public who rescued his children showed considerable bravery and heroism.
"This incident was not anybody's fault in a legal sense and there was no breach of duty to David Fell.
"I find it significant that none of the witnesses put Mr Fell at the scene of the rescue. He was a strong swimmer and family man and I find it inconceivable that he would not have wanted to participate in the rescue of his children. Nobody heard him shout for help. The next time anyone saw him, he was motionless.
"Dr Scoones at no point offered drowning as the cause of death. I asked him to review his evidence in light of the witness statements, and it seems that the stress of entering the water may have increased the risk of cardiac arrest from underlying heart disease. The emergency involving his children exacerbated this stress.
"It is an understandable assumption made on the day that he drowned, but this is not proved and the medical evidence is categorically that he did not drown. The cause of death is natural, but in my view this does not do justice to the circumstances."
Mr Longstaff added that the warning signs now in place were more informative than those present in July 2021, but added that he had no issue with the content of the previous signage.