A coroner investigating the death of a three year old thrown from a seaside trampoline has said another child could die unless safety improvements are made.
Ava-May Littleboy, from Lower Somersham in Suffolk, died in hospital after the apparatus she was playing on exploded on the sands at Gorleston on July 1, 2018.
An inquest into her death found she died of a traumatic head injury.
The trampoline had failed an independent inspection just four days before.
Norfolk coroner Jacqueline Lake has now said she is so concerned she has sent a Prevention of Future Deaths report to the British Standards Institution (BSI), the organisation she says has the power to take action.
Published on April 2 in the “child death” category the report outlines the coroner’s main concerns where action should be taken, detailing the circumstances of Ava-May’s death and highlighting where failings could lead to future deaths.
It notes the trampoline had no instruction manual and no up-to-date and complete risk assessment.
Furthermore there was no procedure in place to safely manage the inflation of the trampoline and no staff training.
Children were supervised by staff while they were on it “some of the time.”
Her main concerns focused on the testing and registration process.
She noted the trampoline was inspected by an independent third party four days before it burst when concerns were raised about it not having any pre-use manufacturing paperwork, and that not all the tie-downs being used.
But because it was not registered under the Amusement Device Inspection Procedures Scheme (ADIPS), or similar body, the defects which made it “of imminent danger to persons” were not flagged or recorded.
It meant there was no public record that a declaration of operational compliance (DOC) had not been issued.
Ms Lake went on to take issue with the fact there was no requirement for the Health and Safety Executive or the local authority to be informed that the equipment was deemed unsafe to use.
She was also concerned there was no legal requirement for an operator to use either the ADIPS or PIPA inspection process but could rely on an alternative form of scheme or method of their own choosing to demonstrate the device is safe to use.
The BSI has a legal duty to respond to the recommendations within 56 days.
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