Recurring concern

Unreliable safety CCTV monitoring systems

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First reported 12 Mar 2014•Latest report 3 Apr 2025

Definition

What this concern includes

Includes failures of CCTV systems used for safety-critical monitoring across care, transport, public-access, custodial and operational settings, including coverage, availability, functionality, access, live monitoring, staff guidance, review, retrieval and provision of effective alternatives when CCTV is unavailable.

Not included

  • Excludes CCTV used solely for general security, crime detection or retrospective evidence where no safety-monitoring function is identified.
  • Excludes failures limited to police access to CCTV information, custody CCTV monitoring, high-risk-location access monitoring or another separately named CCTV system when that narrower concern is the supported boundary.
  • Excludes generic staffing, training, communication or IT deficiencies unless they directly impair safety CCTV monitoring.
  • Excludes the underlying hazard or incident when no deficiency in the safety CCTV system is asserted.
Reports
23

Distinct published reports

Individual concerns
30

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
11

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.

HM Prison and Probation Service2
Home Office2
Recipient name withheld2
Transport for London2
ACR Leisure Limited1
Alton Towers Resort1
Arriva Rail North Limited1
Birmingham City Council1
Calderdale Borough Council1
Canals and Waterways Agency1
Care Quality Commission1
Care UK1
Department for Transport1
Department of Health and Social Care1
Docklands Light Railway Limited1

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. Inner North London

    AI-generated summary

    Kamal Yahyia AL-HIRSI · 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

    Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his death.

    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

    CCTV failing to provide visibility of the pool underwater and in blind spots

    Wider context from the report

    “8. The pool was not under continuous supervision and there was no legal requirement for a lifeguard, but it was under CCTV surveillance. However, the camera was placed at such a position that it could not detect what was happening under water, and there was a blind spot in that part of the pool nearest the camera. After Mr Al-Hirsi slipped under water, he was completely invisible to the camera. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 4 · 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 maintain effective CCTV monitoring of the pool

    Wider context from the report

    “9. The CCTV monitor was in reception. This was meant to be observed every 15 minutes (to ensure maximum bather load had not been exceeded, rather than to look for bathers in distress), but these observations had fallen out of practice, and the monitor was behind the head of the receptionist, so it was never in her normal field of view. She had to turn her back on the public to look at it. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 4 · 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

    Reposition Maida Vale pool CCTV cameras and add cameras to remove the identified blind spot.

    Verbatim wording from the response

    “The Company has undertaken a review of its CCTV coverage of the pool at its Maida Vale Club and has commissioned the work for the repositioning of the CCTV cameras. These works will be completed by 31 October 2018 and will include additional cameras to remove the blind spot noted at the Inquest. It should be noted that the purpose of these cameras is to monitor the number of people within the poolside environment as identified in HSG179. The images from these newly positioned cameras will be available to view on the monitor at reception.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 4 · response
    Published 11 October 2018

    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

    Move the Maida Vale CCTV monitor into receptionists’ constant line of sight.

    Verbatim wording from the response

    “The Company has moved the CCTV monitor at its Maida Club to a more suitable location so that the CCTV monitor is in the constant line of sight of its Receptionists. The Company has also reinstated the 15 minute CCTV checks at its Maida Vale Club, which formed part of the Company’s Normal Operating Procedure and risk assessments.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 5 · response
    Published 11 October 2018

    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

    Reinstate 15-minute CCTV checks at Maida Vale.

    Verbatim wording from the response

    “The Company has moved the CCTV monitor at its Maida Club to a more suitable location so that the CCTV monitor is in the constant line of sight of its Receptionists. The Company has also reinstated the 15 minute CCTV checks at its Maida Vale Club, which formed part of the Company’s Normal Operating Procedure and risk assessments.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 5 · response
    Published 11 October 2018

    Open published response
  2. Manchester South

    AI-generated summary

    Casper Blackburn · 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

    Casper Blackburn died in the early hours of 1 October 2017 after entering the Bridgewater canal in unclear circumstances; the medical cause of death was drowning. Concern was raised that extremely poor lighting, and the absence of CCTV, made the canal difficult to distinguish from the surrounding grass verge and path, 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 CCTV coverage in the area

    Wider context from the report

    “The lighting in the area where Casper likely accidentally entered the canal was extremely poor. There is no CCTV in the area and therefore what precisely happened on the morning of Casper’s death is unclear. Evidence was heard that police attended the scene at night on a date following Casper’s death. The area was so dark that it was very difficult to discern the canal from the grass verge or the path. I am concerned that future deaths might occur if action is not taken to address this. ”

    Source location

    Casper Blackburn · 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

    The Council has limited ability to act because it neither owns the canal path nor controls the public right of way.

    Verbatim wording from the response

    “Unfortunately, the Council has a very limited ability to take direct action as it is not the relevant landowner in respect of the path which runs alongside the canal, nor is it responsible for the public right of way which runs over that path. In both instances the responsible party is the Bridgewater Canal Company Limited. However, the Council has approached the Bridgewater Canal Company to seek to find a resolution to improve the safety of the users of the path and to improve safety measures.”

    Source location

    2018-0094-Responses_Redacted
    Page 1 · response
    Published 17 June 2018

    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

    Responsibility for the canal path and public right of way rests with Bridgewater Canal Company Limited.

    Verbatim wording from the response

    “Unfortunately, the Council has a very limited ability to take direct action as it is not the relevant landowner in respect of the path which runs alongside the canal, nor is it responsible for the public right of way which runs over that path. In both instances the responsible party is the Bridgewater Canal Company Limited. However, the Council has approached the Bridgewater Canal Company to seek to find a resolution to improve the safety of the users of the path and to improve safety measures.”

    Source location

    2018-0094-Responses_Redacted
    Page 1 · response
    Published 17 June 2018

    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 Canal & River Trust has no jurisdiction or responsibilities regarding the Bridgewater Canal or land at the incident location.

    Verbatim wording from the response

    “However, the Canal & River Trust has no jurisdiction or responsibilities regarding the Bridgewater Canal or the land at this location. I believe this is in fact the responsibility of Peel Holdings and because I can see that the Regulation 28 report is being sent to Peel Holdings, in the circumstances I do not believe the Trust is required to take any further action.”

    Source location

    2018-0094-Responses_Redacted
    Page 4 · response
    Published 17 June 2018

    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

    Responsibility for the Bridgewater Canal and location is attributed to Peel Holdings, so the Trust considers further action unnecessary.

    Verbatim wording from the response

    “However, the Canal & River Trust has no jurisdiction or responsibilities regarding the Bridgewater Canal or the land at this location. I believe this is in fact the responsibility of Peel Holdings and because I can see that the Regulation 28 report is being sent to Peel Holdings, in the circumstances I do not believe the Trust is required to take any further action.”

    Source location

    2018-0094-Responses_Redacted
    Page 4 · response
    Published 17 June 2018

    Open published response
  3. East Riding and Hull

    AI-generated summary

    Kellie Marie TAYLOR formerly known as Kellie Marie DANVILLE · 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 Marie TAYLOR, formerly known as Kellie Marie DANVILLE, died after jumping from the Humber Bridge into the river below. The concern was that the existing CCTV system did not provide images of sufficient quality to enable those monitoring it to accurately see behaviour or activities at the bridge, potentially delaying intervention.

    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 of CCTV image quality to support accurate monitoring of bridge activity

    Wider context from the report

    “I am concerned that if other individuals go to the bridge with the intention of jumping off or any other emergency were to occur, the quality of the TV system as it is now is such that their behaviour or activities cannot be accurately seen by those monitoring the system and as a consequence, intervention may not be provided in a timely fashion. ”

    Source location

    Kellie Marie TAYLOR formerly known as Kellie Marie DANVILLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Exeter and Greater Devon

    AI-generated summary

    Stephen Mark SHAYLOR · 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

    Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.

    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

    Reliance on continuous CCTV monitoring to detect prisoner self-harm

    Wider context from the report

    “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming. ”

    Source location

    Stephen Mark SHAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. East London

    AI-generated summary

    Bernard Aziengbe Ovu · 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

    Bernard Aziengbe Ovu entered a non-public area of Canning Town Station and was later seen falling down emergency exit stairs to the DLR platforms. He was found several hours later and died from a head injury. Concerns included an incorrect assumption that he had left the non-public area, the lack of clear written procedures for lone-working staff, difficulties accessing recorded CCTV, and inconsistent dissemination of policies and procedures.

    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 clear staff guidance on use of recorded CCTV

    Wider context from the report

    “There was an inconsistency amongst witnesses as to whether the recorded CCTV should be accessed by staff. Indications were given that access to the recorded CCTV can be practically difficult (the recorded CCTV being BTP equipment and not LU). Recourse to the CCTV would have provided a confirmatory check in these circumstances. It would be helpful for staff to be clear about the use of the recorded CCTV and for ease of access to it. ”

    Source location

    Bernard Aziengbe Ovu · 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

    Difficulty accessing recorded CCTV

    Wider context from the report

    “There was an inconsistency amongst witnesses as to whether the recorded CCTV should be accessed by staff. Indications were given that access to the recorded CCTV can be practically difficult (the recorded CCTV being BTP equipment and not LU). Recourse to the CCTV would have provided a confirmatory check in these circumstances. It would be helpful for staff to be clear about the use of the recorded CCTV and for ease of access to it. ”

    Source location

    Bernard Aziengbe Ovu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Norfolk

    AI-generated summary

    MAYA GRACE KANTENGULE · 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

    Maya Grace Kantengule, aged 7, was found unresponsive at the bottom of a swimming pool during a birthday party on 1 May 2016 and was declared dead later that day. The concerns included the absence of a separate risk assessment for swimming pool birthday parties, failures to follow safety procedures and check compliance, non-functioning CCTV, limited staff awareness of pool-area health and safety, and a lack of formal health and safety training.

    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 maintain working CCTV for checking the pool area

    Wider context from the report

    “(3) Although safety procedures had not been followed on the morning of the swimming pool party, such as going through safety rules with the pool hirer and signing of documentation, and in addition the CCTV (an additional measure used by WRC to check on the pool area) was known to not be working, no checks were made on the pool party by members of staff to ensure safety rules were understood and followed. ”

    Source location

    MAYA GRACE KANTENGULE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. East Sussex

    AI-generated summary

    Sabrina Michelle Walsh · 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

    Sabrina Michelle Walsh was detained under the Mental Health Act at Woodlands Acute Care and was found hanging with a ligature around her neck. The inquest concluded that she deliberately attached the ligature, but the evidence did not fully explain whether she intended a fatal outcome; this was contributed to by neglect. Concerns included the lack of formal risk assessment, inadequate observations and the absence of CCTV in corridors and communal areas.

    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 CCTV in corridors and communal areas for locating vulnerable patients

    Wider context from the report

    “The lack of CCTV in corridors and communal areas at Woodlands Acute Care, St Leonards on Sea, which would enhance location of vulnerable patients where observations do not immediately locate them. Valuable minutes would be saved in locating vulnerable patients if CCTV was installed. ”

    Source location

    Sabrina Michelle Walsh · 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

    Install CCTV in the entrance areas of all 12 Acute Inpatient and PICU wards, including Woodlands.

    Verbatim wording from the response

    “As a result of the information we now have available to us, I confirm that the Trust is in the process of implementing the installation of CCTV in the entrance areas of all our Acute Inpatient/PICU wards, which is a total of 12 sites, including Woodlands.”

    Source location

    2017-0449-Response-by-Sussex-NHS-Trust
    Page 1 · response
    Published 14 July 2017

    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

    Intrusive CCTV in everyday communal living areas is not advisable; CCTV should be limited to entrances and main access pathways.

    Verbatim wording from the response

    “The national steer from NHS England (which I’m aware is being forwarded directly to you), now states that CCTV would be advisable in the areas where people enter the unit and the main pathways in. However, it would not be advisable to have intrusive cameras in everyday areas such as common living areas shared by patients.”

    Source location

    2017-0449-Response-by-Sussex-NHS-Trust
    Page 1 · response
    Published 14 July 2017

    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

    Current CCTV guidance for non-secure mental health units is considered proportionate, so intrusive cameras in common areas are not advised.

    Verbatim wording from the response

    “Professor Kendall’s advice for non-secure units such as Woodlands Acute Care is that CCTV would be advisable in the areas where people enter the unit such as the entrance and the main pathways in. However, it would not be advisable to have intrusive cameras in everyday areas such as common living areas shared by patients. CCTV should not be placed in bedrooms or shower areas.”

    Source location

    2017-0449-Response-by-NHS-England
    Page 2 · response
    Published 14 July 2017

    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

    Care providers, rather than CQC, decide whether to use surveillance; CQC does not require providers to install CCTV.

    Verbatim wording from the response

    “to use surveillance is for care providers to make in conjunction with the people who use the service... This document does not give guidance on whether or not you use surveillance and CQC does not require providers to do so.” It also states that: “We would be concerned by an over-reliance on surveillance to deliver key elements of care, and it can never be a substitute for trained and well supported staff.””

    Source location

    2017-0449-Response-by-NHS-England
    Page 2 · response
    Published 14 July 2017

    Open published response
  8. Cheshire

    AI-generated summary

    Thomas Coyne · 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

    Thomas Coyne consumed alcohol at a stag party, inadvertently entered Earlestown Railway station, accessed the railway lines and was struck by a passing train on 21 May 2016. Concerns were raised that station CCTV did not cover all platform areas and that there was no physical barrier at the end of platform three, allowing access to the tracks.

    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 of station CCTV to cover all platform areas

    Wider context from the report

    “1. The CCTV installed at the station and which can be monitored by the staff on duty, does not actually cover all the platform areas, and thus the member of staff could not see Mr Coyne (who was the only passenger on the station at the time) as he mistakenly wandered on to the tracks. ”

    Source location

    Thomas Coyne · 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

    The station is not considered high risk under the criteria used to prioritise CCTV coverage extensions.

    Verbatim wording from the response

    “The CCTV system does not extend to the entirety of every platform area on all 500 stations. As the system is developed it has been necessary to prioritise extensions and this has been done by reference to the risk profile of each station, by reference to a diverse range of factors, including the incidence of suicide, vandalism, theft and antisocial behaviour. Earlestown is not considered a high risk station on this evaluation.”

    Source location

    2017-0207-Arriva-Rail-North-Limited
    Page 1 · response
    Published 28 July 2017

    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

    CCTV coverage expansion must proceed incrementally across the entire network rather than being delivered immediately at every station.

    Verbatim wording from the response

    “As CCTV technology evolves, it is hoped to expend the coverage area and quality of the images produced, but this must inevitably be an incremental programme across the entire network.”

    Source location

    2017-0207-Arriva-Rail-North-Limited
    Page 1 · response
    Published 28 July 2017

    Open published response
  9. Blackpool and the Fylde

    AI-generated summary

    Jane Bell · 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

    Jane Bell drowned in a hotel swimming pool after going underwater in the deep end and later died in hospital on 14 August 2014. The principal concern was that the hotel’s arrangements for pool supervision, including CCTV monitoring and infrequent poolside patrols, remained insufficient to prevent future deaths, particularly where staff could be distracted and a child could remain underwater for a fatal period.

    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 maintain constant pool monitoring while reception staff perform other tasks

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 4 · 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

    Provide constant poolside supervision through trained patrol and reception CCTV monitoring whenever the pool is open.

    Verbatim wording from the response

    “Since the inquest the Hotel has had constant poolside supervision in place at all times when the pool is open regardless of whether it is in use. This involves one member of staff (with poolside responder training) constantly patrolling at the poolside and another member of staff (also poolside responder trained) continually monitoring the CCTV footage from the reception desk.”

    Source location

    Jane-Bell-Response
    Page 1 · response
    Published 22 March 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

    Constant supervision will cease after reducing pool depth because none of the other HSG79 criteria applies.

    Verbatim wording from the response

    “The requirement for constant supervision under HSG79 will cease once the depth of the pool is reduced as none of the other criteria within the guidance applies. However, the CCTV will continue to be monitored to ensure that bathers are complying with the rules and regular bather head counts will be taken. Pool water testing will also remain at 2 hourly intervals and during these checks staff will monitor the pool and those in it.”

    Source location

    Jane-Bell-Response
    Page 2 · response
    Published 22 March 2016

    Open published response
  10. County Durham and Darlington

    AI-generated summary

    Kyle David Michael Hull · 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

    Kyle David Michael Hull, a 15-year-old teenager, suffered fatal injuries after falling through a fragile roof at the Auction Mart. Concerns were raised about limited CCTV coverage and whether more extensive CCTV and monitoring could help identify risks and enable earlier intervention, particularly around dangerous and fragile roofs.

    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

    Limited CCTV coverage and access via a Council system

    Wider context from the report

    “Evidence was given about limited CCTV coverage and access thereto via a Council system. This may not be adequate and consideration ought to be given as to whether a more extensive CCTV installation and monitoring thereof may be able to alert the Company and/or others to potential risks of people harming themselves and/or damaging the property and early intervention might be helpful and further, such CCTV may be able to better identify particularly high risk areas, especially dangerous and fragile roofs. ”

    Source location

    Kyle David Michael Hull · 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

    Failure of CCTV monitoring to alert relevant parties to risks and identify particularly high-risk areas

    Wider context from the report

    “Evidence was given about limited CCTV coverage and access thereto via a Council system. This may not be adequate and consideration ought to be given as to whether a more extensive CCTV installation and monitoring thereof may be able to alert the Company and/or others to potential risks of people harming themselves and/or damaging the property and early intervention might be helpful and further, such CCTV may be able to better identify particularly high risk areas, especially dangerous and fragile roofs. ”

    Source location

    Kyle David Michael Hull · 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

    Seek financing and make a final board decision on installing a night-vision, motion-detecting CCTV system linked to management’s mobile phones.

    Verbatim wording from the response

    “Since the inquest we have had two CCTV firms out to measure the site, both have taken time in what type of CCTV would be needed, the number of CCTV’s, maximising the area of coverage as the design of the mart makes it extremely hard to cover every corner. The conclusion was that CCTV’s with night vision, movement detection and linkage to the internet where the images can be streamed to Mobile phones of company management.”

    Source location

    2015-0379-response
    Page 1 · response
    Published 19 October 2015

    Open published response
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Data last updated 7 September 2026