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A five-day inquest into the death of a man who went into the sea after his dog has concluded today with a verdict of misadventure.
Nicholas Warren, 57, from West Hougham near Dover, was recovered from the water by RNLI volunteer crews on Sunday, November 29 2015 after he jumped in to save his puppy.
The father of two was recovered face down in the water by Kingsdown Rifle Range within 22 minutes of the emergency call. He was then given continuous CPR but remained unresponsive and later died.
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Area coroner for North East Kent Alan Blundson concluded that Mr Warren's death was a result of misadventure.
Summing up, he highlighted how much discussion during the five-day hearing at Sandwich Guildhall had centred around how care of Mr Warren could have been transferred to SECamb rather than the Coastguard's search and rescue helicopter.
It was learnt that there had been no qualified paramedic on-board the aircraft which took Mr Warren from the beach at Walmer to the QEQM Hospital in Margate - instead the winchman was a technician retraining to become a paramedic.
Meanwhile, South East Coast ambulance's paramedics were on the ground with the relevant equipment, and a critical care team carrying a Lucus chest compression machine were just 11 minutes away.
Mr Blunsdon referred to the "lack of discussion or planning strategy" between the two agencies as information about each others involvement had not been communicated by the Coastguard.
However, he concluded: "The evidence from doctors is that Mr Warren's chances of survival were non-existent and even if he had been rescued three to four minutes sooner, it is probable that it would have been the same sad outcome.
"Whether care was given by the ambulance service or search and rescue, it wouldn't have changed the outcome."
Dr Susan Coleshaw, a survival expert who has undertaken extensive research into the cause and consequences of hypothermia, had travelled from Aberdeen to give evidence at the hearing on Thursday.
Based on data she predicted the sea temperature would have been 12C which she described as "painfully cold to the exposed skin".
Combined with winds of 35 to 40 knots and a calculation that Mr Warren was face down in the water for 16 to 17 minutes, she said: "It seems unlikely to me that Mr Warren could have survived and that resuscitation would have been successful."
Dr Jonathan Hill, a specialist in interventional cardiology based at Kings College in London, told the hearing: "In retrospect all CPR efforts would have been futile. The chances of success were zero."
At the beginning of the five-day inquest, Mr Blunsdon had referred to the possibility of producing a Regulation 28 Report to the chief coroner, whereby a coroner feels duty bound to raise points which could prevent other deaths.
However he said, based on evidence he'd heard, that he felt that steps were already being taken to ensure more effective communications between the emergency services were now taking place.
Speaking afterwards, Matt Pavitt, HM Coastguard's coastal operations area commander for the south east, said: "As part of the helicopter project, over the last three years we've taken over the running of the search and rescue helicopters from a mixture of Coastguard, RAF and Royal Navy helicopters, that's now all co-ordinated within the Coastguard at our operations centre in Fareham.
"Whereas before we had a situation where some of that coordination was done up in Scotland, it's now done in exactly the same room, with exactly the same systems as Coastguard officers all around the country."
Mr Blunsdon concluded the inquest by paying tribute to the commitment and dedication of the services involved.
Mr Warren's daughter, Lisa Rogers, who was present throughout the hearing, joined him in commending their efforts.
Having waited almost three years for her father's inquest, she told Kent Online: "I've had moments when I've been angry and moments when I've been in awe and I have nothing but inspiration for the rescue services that took part in the search and rescue of my dad.
"I have to admit - with grief as well - I have blamed each and every one of them at one point in time but we were waiting on medical evidence from a heart specialist and a pathology report to confirm whether there were any delays or anything that could have caused the death of my father.
"As it was, that isn't the case.
"Sadly, despite all of their best efforts, there's nothing else they could have done. They absolutely tried and did everything they could."
Ms Rogers said her dad was one of the strongest men she knew and described him as "more of a mate than a dad".
She added: "On behalf of my family, I'd like to say how grateful I am to all that took part in the search and rescue of my dad especially the RNLI group.
"The crew there are volunteers, one of whom was 17 at the time, and that really has touched my heart. I'm inspired by all of them."
Mr Pavitt, of HM Coastguard, added: "This week has shown that all of the emergency services continue to develop and alter the way we work.
"It's shown that tragically, despite the best efforts of everybody, sometimes it is not possible for us to save people for a number of reasons.
"It has shown us the importance of collaborative working, that we all work well together for the best interests of those involved."
He would like to remind people of the dangers of going into the sea after a pet.
He said: "We know dogs are a really emotive subject, people will do their utmost to look after their dogs but if you're in trouble or your dog is in trouble, don't hesitate, dial 999."