Recurring concern

Inadequate controls for cold-water immersion risks in open water

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First reported 18 Jan 2018•Latest report 4 Oct 2023

Definition

What this concern includes

Includes dedicated controls for preventing, detecting or responding to cold-water immersion risks during organised or supervised activities in rivers, lakes, reservoirs and comparable open-water locations, including assessment of water-entry conditions and participant acclimatisation, safety briefings, supervision, suitable equipment, rescue planning and emergency response.

Not included

  • Excludes general open-water drowning controls where cold-water immersion is not a material part of the asserted unsafe condition.
  • Excludes generic training or competence deficiencies unless they directly concern managing cold-water immersion risks.
  • Excludes ordinary pool or water-tank activities unless the assertion explicitly concerns comparable cold-water immersion hazards.
  • Excludes clinical recognition or treatment of immersion-related illness after the emergency response has operated reliably.
  • Excludes general water-quality, pollution, boating or watercraft hazards unrelated to cold-water immersion.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Education1
Health and Safety Executive1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Kellie Jean POOLE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kellie Jean POOLE died on 25 April 2022 after collapsing during a led cold water immersion session in the River Goyt. The report states that cold water likely triggered a heart rhythm disturbance and that she had an abnormal heart. The principal concerns were the limited oversight and regulation of cold water immersion providers, including health warnings, safety measures, leader training, first aid provision, insurance, risk assessments and guidance from relevant authorities.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient training and experience of cold water immersion session leaders

    Wider context from the report

    “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance. ”

    Source location

    Kellie Jean POOLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Risk posed by open-water locations used for cold water immersion sessions

    Wider context from the report

    “Some sessions take place in water tanks, but sessions are also held in open water such as rivers, lakes, and reservoirs, and therefore at locations that may in themselves pose risk. Session leaders may have undertaken some form of training, but I am not aware that the nature and quality of the training itself is regulated/quality assured. ”

    Source location

    Kellie Jean POOLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing legal requirements and guidance from multiple authoritative sources are considered sufficient, so HSE will not publish specific cold water immersion guidance now.

    Verbatim wording from the response

    “well as targeted guidance for higher-risk industries and activities. HSE does not seek to provide guidance for all industries and activities as it is often the case that others are more knowledgeable or better placed to provide such guidance.”

    Source location

    Response from Health and Safety Executive
    Page 2 · response
    Published 6 October 2023

    Open published response

  2. Inner South London

    AI-generated summary

    Master Abdul-Jamal Ottun · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Master Abdul-Jamal Ottun, a 17-year-old school student, drowned while swimming in Shawnigan Lake, British Columbia, during a school rugby tour on 12 July 2015. The principal concerns were the adequacy of risk assessment and supervision, including the lack of consideration of a lifeguard, the risks of cold open water, the safest entry point, necessary equipment, and rescue arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess the risks of unacclimatised swimmers entering cold open natural waters

    Wider context from the report

    “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”

    Source location

    Master Abdul-Jamal Ottun · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026