Corfu inquest – HM Coroner David Hinchliff’s Reg. 28 report to prevent future deaths




3144/2006 – 3145/2006






Before Senior Coroner, David Hinchliff

A Jury was duly sworn




This report is being sent to:


  • Thomas Cook Group c/o Fieldfisher LLP Solicitors, Riverbank House, 2 Swan Lane, London, EC4R 3TT


  • Louis Group including the Louis Corcyra Beach Hotel c/o of Hill Dickinson LLP Solicitors, The Broadgate Tower, 20 Primrose Street, London, EC2A 2EW


  • The Secretary of State for the Department for Culture, Media and Sport, 100 Parliament Street, London, SW1A 2BQ


  • The Secretary of State for the Foreign and Commonwealth Office, King Charles Street, London, SW1A 2AH


  • The Federation of Tour Operators, Graphic House, 14-16 Sussex Road, Haywards Heath, RH16 4EA


  • The Secretary of State for the Department of Trade and Industry, 1 Victoria Street, London, SW1H 0ET


  • ABTA – The Travel Association, 30 Park Street, London, SE1 9EQ





I am David Hinchliff, Senior Coroner for the Eastern Area of West Yorkshire.


Coroner’s Legal Powers


I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.




On 3rd November 2006 I opened Inquests touching the deaths of Christianne Shepherd, aged 7 and Robert Shepherd aged 6. The Inquest concluded on 13th May 2015. The Conclusion of the Inquest was in Narrative form as follows. The medical cause of death was 1(a) Carbon monoxide poisoning


The Conclusion was in Narrative form, namely:-


  1. Incorrectly installed and badly maintained boiler
  2. Fuel protection device disconnected deliberately
  3. Air conditioning pipes badly fitted
  4. Hotel misled/lied to the Tour Operator about gas supplied to the hotel bungalows
  5. Resort Audit carried out in 2004 by the Tour Operator was inadequate
  6. Monthly Health and Safety Audit form inadequate, did not reflect the Tour Operator’s Health and Safety Policy/Guidelines
  7. Resort Staff not given enough Health and Safety information regarding how to identify the presence of gas/electric water heaters
  8. Resort Audit in 2004 was incomplete, checks not carried out vigilantly as stated in the Tour Operator’s Training Manual (Boiler room not identified)
  9. The Tour Operator breached their duty of care




Christianne and Robert Shepherd were taken on a half-term holiday from 22nd to 30th October 2006 by their father and his then partner, to the Greek island of Corfu. The Tour Operator was Thomas Cook. The family stayed at the Louis Corcyra Beach Hotel in Gouvia. The allocated accommodation was a semi-detached bungalow situated in the grounds of the hotel. Water heating and air conditioning was from an LPG water heater located in a separate annex, which was attached to the bungalow. The water heater was badly installed and defective, and dangerous in that in-built safety devices had been deliberately disconnected. The water heater had not been serviced or maintained, causing carbon monoxide fumes to escape into the bungalow through defective building and piping. Whilst occupying the bungalow all the occupants were victims of carbon monoxide poisoning causing the deaths of the children and the near deaths of the adults.




During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.


The MATTERS OF CONCERN are as follows:-


  1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period.


  1. In most situations a hotel, apartment or other holiday premises will be used by more than one Tour Operator. In this event a system should be devised for Tour Operators to work in collaboration with communicate and actively share information pertaining to Health and Safety issues.


  1. There should be awareness raising and Health and Safety promotion activities undertaken to make travellers aware of the dangers of carbon monoxide poisoning and to promote the benefits of travelling with a portable carbon monoxide detection device. This could effectively be achieved by being linked to promotion of the E111 European Health Insurance Card Scheme.


  1. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety.   Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.


  1. Arising from recommendation (4) above, Tour Operators and the owners and controllers of hotels, apartments and holiday premises should devise and/or subscribe to suitable Health and Safety accreditation ratings.


  1. Within the structure and hierarchy of every provider of hotels, apartments and holiday premises there should be a robust internal structure for a system of management, supervision support and training in respect of Health and Safety issues.


  1. All holiday brochures and travel promotional literate and Health and Safety information should be written in clear, easy to understand language and should make specific reference to the dangers of carbon monoxide poisoning, and make reference to safeguards that travellers should adopt.


  1. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises.


That the Government should do its utmost to encourage and promote through legislation and improvement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.


I am aware that recent attempts to introduce such legislation has not progressed. It is my desire that this recommendation should produce a renewed initiative for EU legislation requiring the installation of carbon monoxide detectors by Tour Operators and holiday accommodation providers.


  1. I acknowledge that to introduce legislation as recommended herein may be a slow and tedious procedure, which may, as has previously happened, fail. I therefore recommend that the travel industry, although supporting and providing their own initiative to relevant government departments. The industry should, nevertheless, endeavour to regulate itself by introducing industry wide initiatives and improvements in the Health and Safety of holiday makers, particularly with regard to carbon monoxide poisoning issues. Thomas Cook, one of the largest providers of holiday accommodation in the world should be at the forefront of such initiatives to create industry wide protocols and initiatives on the lines that legislation would introduce, should that ever occur.


  1. It is my understanding that ABTA, The Travel Association, to whom this report is being sent, produces the ABTA Technical Guide for Accommodation Suppliers, which has a section dedicated for fuel management, and is reviewed every five years. This will next be reviewed in 2016. These recommendations, where relevant to ABTA’s review, are timely and I recommend that where relevant my concerns listed at (1) to (9) herein, should be considered and incorporated in the next edition.




In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.




You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16th November 2015. I, the Coroner, may extend the period.


Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.




I have sent a copy of my report to the Chief Coroner and to the following interested persons:


  • Stephanie Trotter, OBE, President and Director of CO-Gas Safety, Priory Cottage South, Priory Road, Seaview, Isle of Wight, PO34 5BU


  • Mary Creagh MP, Member of Parliament for Wakefield, 20-22 Cheapside, Wakefield, WF1 2TF


  • David Weston, Chief Executive of The Bed and Breakfast Organisation, Belfry House, Batts Field, Bruton, BA10 0DX


  • Linda McAvan MEP, 79 High Street, Wath-upon-Dearne, Rotherham, South Yorkshire, S63 7QB


  • Professor the Baroness Finlay of Llandaff, Co-Chair of the All-Party Parliamentary Carbon Monoxide Group, House of Lords, London, SW1A 0PN


I am also under a duty to send the Chief Coroner a copy of your response.


The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.



18 September 2015  


……………………………………………. Senior Coroner, West Yorkshire (Eastern Area)

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