'Uncommon water hazards' will now be identified as part of Thomas' legacy
On July 27, 2020, Thomas Branchflower was found in a garden rainwater trough and emergency services called
Last updated 16th Dec 2021
A narrative verdict was today recorded at an inquest into the death of a 16-month old disabled boy, who was found in a water trough last Summer in Somerset.
Coroner Tony Williams today heard Somerset County Council has since updated guidance, both locally and with national organisations, to identify potential 'uncommon water hazards' as part of their assessment process.
Thomas Branchflower had been placed on the ground just outside the back door in Williton on July 27, 2020, while his foster mum checked emails - sometime after 4.30pm to just after 5pm - and was found in a trough when she went back to check on him.
The qualified nurse called 999 after trying to administer 'rescue breaths' and a helicopter and land-based paramedics were dispatched to the scene.
Following their intervention Thomas 'started to respond to treatments' and was initially taken by land ambulance to Taunton's Musgrove Park Hospital.
Sadly Thomas died five days later at Bristol Children's Hospital on August 1.
Thomas had a condition associated with a cognitive disability and a form of visual impairment. A preliminary cause of death was originally recorded as 'hypoxic ischaemic brain injury secondary to drowning', which the coroner today confirmed as the cause of death.
Somerset County Council later set up a review following the case.
The inquest heard that no hazards had been identified for an under five at the property and a social worker had made eight visits to the property as part of the assessment process.
A general advice handbook was given to the family to 'reduce or manage' any 'potential risks' and there had been a 'lot of contact' with the family as part of the standard placement process - but health and safety matters were not 'revisited' in discussions with the foster family.
The review found Somerset County Council's systems were 'generally sound' but called for extra training and advice to highlight potential water hazards - away from the traditional pond or swimming pool-type risk.
It also called for ongoing reviews to 'identify new hazards' and include items later brought into the home after the original assessments.
Before closing the inquest, coroner Williams today said he did not feel that he needed to recommend actions to be taken - as they'd already been initiated by Somerset County Council, both locally and in spreading advice nationally.
Somerset County Council have issued this statement: “We continue to offer our sympathies to all those affected by Thomas’s tragic death and remain deeply saddened ourselves.
“As the Coroner noted, following Thomas’s death, we appointed an independent person to review all our health and safety processes relating to foster carers.
“This identified that we had followed national best practice when assessing these foster carers' home. However, it goes without saying that Thomas’s tragic death has shown that best practice nationally needs strengthening.
"As recognised by the Coroner, we have used the report findings to strengthen our own local processes to highlight the potential risks which could be posed by uncommon water hazards. We are committed to sharing these recommendations nationally.
"We thank the coroner for his comprehensive inquiry and we will continue to offer our support to those affected by this tragedy for as long as this is needed."