Recurring concern

Inadequate regulatory oversight of organised public events

Pin Get email alerts Request correction

First reported 26 Jan 2016•Latest report 10 Apr 2025

Definition

What this concern includes

Includes deficiencies in the dedicated regulatory and governance arrangements for organised public events, including powers or processes to require an accountable organiser, establish safety responsibilities, require competent event management, and enforce appropriate risk assessment, briefing, emergency planning or participant-control measures.

Not included

  • Excludes generic legal or regulatory gaps that are not specifically connected to safety governance of organised public events.
  • Excludes operational safety failures at a particular event where no deficiency in event-level regulatory oversight or governance is identified.
  • Excludes ordinary event staffing, training, risk-assessment or emergency-planning deficiencies unless they are explicitly linked to the absence or inadequacy of the organised-event oversight framework.
  • Excludes regulation of products, vehicles, premises or other activities where an organised public event is not the bounded safety concern.
Reports
7

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
5

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 Digital, Culture, Media and Sport3
Department of Health and Social Care2
Health and Safety Executive2
Home Office2
Auto Cycle Union Limited1
Department for Business, Energy & Industrial Strategy1
Department for Culture, Media and Sport1
Department for Transport1
Festival Republic Limited1
Kendal Calling1
Leeds City Council1
Lifeskills Medical (UK) Limited1
Recipient name withheld1
West Yorkshire Police1

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. Sunderland

    AI-generated summary

    Mr Joel Kenneth Ineson · 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

    Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.

    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

    Lack of emergency plans for organised open water swimming events

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report
    Page 1 · 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

    Lack of specific health and safety guidance and compliance requirements for event risk assessments

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · 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

    Lack of regulatory licensing and oversight for organised open water swimming events

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · 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

    Lack of training requirements for open water swimming event organisers

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue supporting and liaising with local-authority regulatory partners on enforcement of work-related health and safety legislation.

    Verbatim wording from the response

    “HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area.”

    Source location

    Response from Health and Safety Executive
    Page 2 · response
    Published 17 April 2025

    Open published response

    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 regulations and guidance provide a suitable basis for safe public open water swimming, so HSE will not publish specific guidance.

    Verbatim wording from the response

    “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

    Source location

    Response from Health and Safety Executive
    Page 1 · response
    Published 17 April 2025

    Open published response

    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

    Enforcement responsibility lies with HSE or the relevant local authority, with local authorities predominantly enforcing work-related health and safety legislation in this area.

    Verbatim wording from the response

    “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

    Source location

    Response from Health and Safety Executive
    Page 1 · response
    Published 17 April 2025

    Open published response

    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

    An AALA licence is not relevant because the licensing scheme concerns specified tuition for children, not adult swimming events.

    Verbatim wording from the response

    “The Adventure Activities Licensing Regulations 2004 have a very specific purpose and were never intended to apply to all adventure activities or adult adventure activities. The Adventure Activities Licensing Authority (AALA) licence is aimed at those who provide tuition in specified adventure activities to children, and therefore it was not relevant to a swimming event for adults.”

    Source location

    Response from Health and Safety Executive
    Page 2 · response
    Published 17 April 2025

    Open published response
  2. Somerset

    AI-generated summary

    Simon Timothy Harding · 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

    Simon Timothy Harding died after becoming separated from his motocross bike during a jump at Granfield Moto-Cross Track on 10 September 2022; the bike landed on his head, causing catastrophic and unsurvivable head injuries. Concerns included limited rider registration, no safety briefing, inadequate track regulation and stewarding, lack of rider segregation, and no first-aid training for venue staff. The report also identified a lack of mandatory minimum safety and risk-management standards for motocross venues as a risk of future deaths.

    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

    Absence of mandatory minimum safety and risk-management standards for motocross venues

    Wider context from the report

    “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information. (b) There did not appear to be any kind of safety briefing for the riders before using the Track. (c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike. (d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track. (e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived. Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity. It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths. ”

    Source location

    Simon Timothy Harding · Prevention of Future Deaths report
    Page 3 · 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

    Responsibility for concerns about a racetrack bike crash lies with DCMS rather than the Department for Transport.

    Verbatim wording from the response

    “Our officials have advised that the matters of concerns raised would not be appropriate for DfT to respond but is for DCMS, as the bike crash happened on a racetrack and not on the public highway.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 6 February 2025

    Open published response

    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

    Practice tracks are not legally required to obtain authorisation to operate under the cited regulations.

    Verbatim wording from the response

    “The ACU is able to authorise motocross events and venues such as practice tracks under the Motor Vehicles (Off Road Events) Regulations 1995, but this is not a requirement for practice tracks to operate. We understand from the ACU that this tragic incident took place at a private motocross practice facility at a venue not known to the ACU, and the event was not regulated or permitted by them or any other authorising body.”

    Source location

    Response from Department for Culture, Media and Sport
    Page 1 · response
    Published 6 February 2025

    Open published response
  3. Worcestershire

    AI-generated summary

    Christopher William Townsend · 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

    Christopher William Townsend died on 8 June 2023 after sustaining multiple chest and abdominal injuries in a motor accident during an organised grass-track motorcycle and side-car race. The report identified concerns about the lack of event-specific risk assessments and a requirement for recorded safety plans at ACU track-racing events, creating a risk of future deaths.

    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

    Lack of a requirement for a recorded event-specific safety plan at National and Club events

    Wider context from the report

    “(2) However, in my questions to ████████ he confirmed that there is no requirement for organisers of events held under the ACU Regulations to prepare an event-specific Safety Plan at either National or Club events. There is such a requirement for ACU events held on an international/European permit (paragraph 3.26 National Sporting Code 2023). ████████ confirmed that whilst it is not an ACU requirement to prepare such a plan for Club/National events it is open to organisers to do so. Appendix 3 of the ACU’s publication provides an example of contents list of an event safety plan. (3) Planning for safety at motorsport events to which the public are admitted must be thorough, comprehensive and verifiable by being recorded. This allows organisers to record and disseminate safety arrangements for their events. The risks may differ in scale, but not substantially in nature, as between international and national/club events. (4) In my opinion, in the absence of such methodical planning and recording there is a risk of future deaths arising from the current arrangements for safety planning at ACU track race events. (5) I have carefully considered ████████ evidence as to the reviews that are being undertaken by the ACU of their procedures and guidance. This was provided in his written evidence, his answers in oral evidence and in the letter from him dated 5 April 2024. I have also carefully considered the cogent submissions on behalf of the ACU by ████████ of DWF, in particular as to Chief Coroner’s Guidance Note 5 (November 2020), especially paragraph 7 thereof. Nonetheless, I remain of the opinion that in the absence of a requirement for a recorded safety plan for each event there is a risk that future deaths will occur. ”

    Source location

    Christopher William Townsend · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require a documented Safety Plan for all ACU-permitted events from the start of the 2025 season.

    Verbatim wording from the response

    “The ACU's Board of Directors have considered the concerns raised and will ensure that a document entitled Safety Plan is a requirement for all ACU permitted events from the start of the 2025 season. The content of the Safety Plan will continue to be discussed by the relevant people within the ACU to ensure that comprehensive guidance is provided to event organisers in readiness for the 2025 season.”

    Source location

    Response from Auto Cycle Union
    Page 2 · response
    Published 31 May 2024

    Open published response
  4. West Yorkshire Eastern

    AI-generated summary

    David Joseph Celino · 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

    David Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.

    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

    Lack of governing oversight of music festivals

    Wider context from the report

    “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem. (3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites. ”

    Source location

    David Joseph Celino · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Write to the Secretary of State supporting a national music-festival oversight body and the availability of national drug-related casualty data.

    Verbatim wording from the response

    “The Licensing Committee draws upon available specialist expertise from the multi-agency SAG in its consideration of the EMP for the Leeds Festival. The Council agrees that guidance, oversight and data from a national governing body for music festivals would be extremely valuable in this process and would welcome such a body being introduced. The Licensing Committee chair will write to the Secretary of State to support the introduction of such a body.”

    Source location

    Response from Leeds City Council
    Page 2 · response
    Published 6 September 2023

    Open published response

    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

    Approval of event licences and any additional conditions is a matter for local authorities.

    Verbatim wording from the response

    “Licence reviews play an important role. Reviews give licensing authorities (and others) powers to address problems, and can be triggered by complaints from local residents or businesses – ensuring appropriate local representation in the decision making processes – or by representations from relevant authorities, such as the police or the licensing authority itself. The approval of event licences - including any additional conditions placed on event organisers - is at the discretion of Local Authorities.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 6 September 2023

    Open published response

    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 local licensing, enforcement, safety-advisory and industry arrangements provide sufficient oversight, making a governing body unnecessary.

    Verbatim wording from the response

    “Governing Body with Oversight of Festivals”

    Source location

    Response from Festival Republic 1
    Page 7 · response
    Published 6 September 2023

    Open published response
  5. Cornwall and Isles of Scilly

    AI-generated summary

    Laura Amy Smallwood · 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

    On 1 May 2019, Laura Amy Smallwood was unintentionally struck on the back of her neck by an Oss during the May Day festival in Padstow. She deteriorated at the scene, suffered a respiratory arrest, and died from her injuries in hospital on 4 May 2019. The principal concern was the absence of a single Event Organiser for the festival, with resulting gaps in engagement with safety agencies and in legislative oversight of public safety.

    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

    Lack of legal powers to require appointment of an Event Organiser

    Wider context from the report

    “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety. I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from: - Inspector ████████; - PS ████████ - ████████ with counsel’s advice. If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police? ”

    Source location

    Laura Amy Smallwood · Prevention of Future Deaths report
    Page 1 · 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

    Lack of legal powers to grant or refuse permission for events with significant public safety concerns

    Wider context from the report

    “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety. I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from: - Inspector ████████; - PS ████████ - ████████ with counsel’s advice. If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police? ”

    Source location

    Laura Amy Smallwood · 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

    Failure to appoint an Event Organiser responsible for whole-event public safety coordination

    Wider context from the report

    “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety. I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from: - Inspector ████████; - PS ████████ - ████████ with counsel’s advice. If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police? ”

    Source location

    Laura Amy Smallwood · Prevention of Future Deaths report
    Page 1 · 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

    Amending the law would not necessarily prevent rare event tragedies, so further legislation is not considered necessary.

    Verbatim wording from the response

    “For that reason, we have taken the view that it is better to support and encourage sensible planning and preparation, rather than to mandate every element of it through legislation. The latest public guidance from the Cabinet Office (Organising a voluntary event: a 'can do' guide - GOV.UK (www.gov.uk)) is intended to help people planning voluntary events, with advice on the steps that organisers should take.”

    Source location

    Response from Home Office
    Page 3 · response
    Published 26 April 2022

    Open published response
  6. Manchester South

    AI-generated summary

    Donald Berry · 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

    Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.

    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

    Lack of nationally replicated site visits for large events

    Wider context from the report

    “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority. 2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this. ”

    Source location

    Donald Berry · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. South London

    AI-generated summary

    Rio Andrew · 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

    Rio Andrew became unwell after taking MDMA at an illegal rave and was taken to the event medical providers. The inquest concluded that he died from multiple organ failure due to acute MDMA intoxication. Concerns included the lack of regulation of medical assistance at temporary events, poor medical knowledge among private medical staff, the unregulated use of the title “ambulance technician”, and inadequate oversight of training mentors.

    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

    Lack of regulation of medical assistance at events

    Wider context from the report

    “(1) The regulation of the private company by the CQC provided false security as to what was in fact being regulated. The only activity that was regulated was transport from the rave in an ambulance on a public road, which activity was not in fact needed because Rio was handed over to the London Ambulance Service outside the venue. The level of medical knowledge displayed by the private medical staff was poor. The exemption for temporary arrangements means that the provision of medical assistance at events is entirely unregulated. This includes not only illegal raves, but legal events such as sporting events, fetes and festivals. ”

    Source location

    Rio Andrew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Consult on whether established year-round event medical providers should be brought within CQC regulation.

    Verbatim wording from the response

    “The Department has become aware of some permanent established companies that provide cover at temporary events. These providers deliver services on a year round basis, to one off events and other social and cultural events. The range of services provided appears to go some way beyond basic first aid and in some cases involves the delivery of services by a multi-disciplinary team. The Department is intending to consult later this year as to whether providers of this sort should be brought into the scope of regulation by CQC. The Department is proposing that permanent nature of these providers, as opposed to the temporary nature of the events they provide services at, does offer sufficient continuity of service that system regulation by CQC could help mitigate the risks of the public receiving unsafe care at events.”

    Source location

    Rio-Andrew-2016-Response-by-Department-of-Health
    Page 2 · response
    Published 26 January 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Raise concerns with the Care Quality Commission about regulation of private ambulance providers’ event medical care.

    Verbatim wording from the response

    “AACE remains concerned that private ambulance providers who are providing medical cover at events remain unregulated by CQC in terms of the medical care they are delivering within the event footprint. We have raised this previously with CQC and whilst we appreciate the additional workload it would bring them it is clear that times the medical care provided can be tragically inadequate. This also brings an unquantifiable additional burden for the statutory ambulance service who have to intervene and also puts patients at risk.”

    Source location

    Rio-Andrew-2016-Response-by-Association-of-Ambulance-NHS
    Page 1 · response
    Published 26 January 2016

    Open published response

    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

    Temporary-event providers remain outside CQC regulation because regulation is ineffective for short events and would impose disproportionate burdens.

    Verbatim wording from the response

    “The CQC does not regulate the “treatment of disease, disorder or injury” where it is delivered under temporary arrangements for the purposes of sporting or cultural events. The rationale for this is because the short term nature of such events means system regulation does not offer an effective mitigation of the risks in the care provided over the course of the event. In most cases, the event would be over before the CQC would have chance to inspect it or provided any sort of assurance about the quality and safety of services provided at the event.”

    Source location

    Rio-Andrew-2016-Response-by-Department-of-Health
    Page 2 · response
    Published 26 January 2016

    Open published response

    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

    The Care Quality Commission should address regulatory oversight of private ambulance medical care provided at events.

    Verbatim wording from the response

    “Having considered the issue and discussed with the National Ambulance Medical Directors Group we did feel that we should write to you to make a few salient points and to encourage your engagement with the Care Quality Commission (CQC) to address the regulatory issues.”

    Source location

    Rio-Andrew-2016-Response-by-Association-of-Ambulance-NHS
    Page 1 · response
    Published 26 January 2016

    Open published response
Back to top

Data last updated 7 September 2026