Theo Treharne-Jones

I am Gavin Knox HM Coroner , for the coroner area of South Wales Central.

On 25 June 2019 I commenced an investigation into the death of Theo Phillip TREHARNE- JONES . The investigation concluded at the end of the inquest on 15 October 2025. The conclusion of the inquest was Accident. 1a Drowning

These were recorded as : Theo Treharne-Jones died on 15 June 2019 by drowning in a swimming pool at The Holiday Village Atlantica, in Kos Greece where he was on holidays with his family. Theo was 5 years old. He could not swim and as a result of a genetic condition had no sense of danger. He accessed the swimming pool, which had no protective barrier, after leaving his hotel room unnoticed while his parents were  asleep. The hotel room locks were of a design that did not secure against Theo leaving the room.

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. Theo was particularly vulnerable in that:

1. He had developmental delay;
2. He had no sense of danger;
3. He was prone to waking during the night;
4. He was fully mobile;
5. He loved swimming and had some sensory needs;  6. He was unable to swim.

The door locks in the hotel room were of a design to promote safety during a fire and could be easily disengaged from the inside; There was no secondary security measure such as a chain in place; Theo’s parents recognised the risk of Theo leaving the room unsupervised and attempted to mitigate this by locking the door and putting additional impediments in the way of the door including 2 pushchairs and an empty suitcase; ABTA guidance does make reference to a security chain/latch but this is the context of enabling customers to identify a visitor at the door and merely states such could be  provided. However, there is no reference in the guidance to any form of security in the sense of controlling the exit from the room. No specific information about door locks and security chains was given to Theo’s parents on booking or on arrival. The pool that Theo was found in did not have any physical barrier in place to prevent  uncontrolled or unsupervised access by children.

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