Recurring concern

Inadequate warnings about location-specific hazards at public waterside locations

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First reported 4 Mar 2014•Latest report 26 Feb 2026

Definition

What this concern includes

Includes inadequate signs, pictograms, public advice or other dedicated warnings about location-specific hazards at beaches, rivers, ponds and comparable publicly accessible waterside locations.

Not included

  • Generic water-safety education not tied to a location-specific hazard
  • Lifeguard, rescue-service or emergency-response capacity where warning controls are not deficient
  • Warnings for roads, workplaces or other non-waterside settings
  • The underlying natural hazard where no deficiency in warning or safety information is identified
Reports
21

Distinct published reports

Individual concerns
23

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
27

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.

Bannau Brycheiniog National Park Authority2
Foreign, Commonwealth & Development Office2
Natural Resources Wales2
Neath Port Talbot County Borough Council2
Powys County Council2
Rhondda Cynon Taf County Borough Council2
Borough Council of King's Lynn and West Norfolk1
Canal & River Trust1
Coal Authority1
Department for Transport1
Derbyshire Constabulary1
Durham County Council1
Environment Agency1
Finchale Abbey Farm1
Gwynedd Council1

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. Cheshire

    AI-generated summary

    William Anthony Elvis WEBB · 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

    William Webb was reported missing after failing to return home and was later found deceased in the Shropshire Union canal on 24 November 2025. CCTV indicated that he likely accidentally fell into the canal on 23 November and died by drowning after being unable to self-rescue. The report raised concerns about the absence of safety equipment and nearby warning signage, and the difficulty of getting out because of the distance between the water and the ground edge.

    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 nearby signage alerting people to the potential risks of the canal

    Wider context from the report

    “The area in which Mr Webb fell into the canal is close to student accommodation. Whilst this is a generalisation and is by no means all students, students as a group are within the demographic of people who will attend the bars, pubs and nightclubs of Chester and become inebriated to varying degrees. Once under the influence of alcohol, or perhaps another substance, it is then not inconceivable that they then take less care/ are more willing to engage in risky behaviours. The canal is near to their accommodation, which makes it more likely that they will be in that area. Once in the water, there is currently no safety equipment which could assist someone in getting out, whether they are in accidentally or intentionally, and the distance between the water level and the ground edge (the freeboard), is, in my view, such that it would be difficult to get out without assistance. There is also no signage nearby which alerts people to the potential risks. I heard varying evidence as to the depth of the water, with the police describing it as around 5ft, and the Canal and River Trust indicating it was around 1 metre. ”

    Source location

    William Anthony Elvis WEBB · 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

    Coordinate with the Water Safety Partnership and relevant landowners to identify and discuss potential additional water-safety mitigation measures.

    Verbatim wording from the response

    “• Consequently and to address the specific risks presented by the public realm over which the Trust has no control, I have, on behalf of the Trust, requested the WSP’s support in writing to relevant riparian owners of the land surrounding the Shropshire and Union Canal, inviting them to a meeting to discuss what further steps can be taken collectively, or on an individual basis to provide additional mitigation of water safety risks in this area. Layout of the public realm, signage, lighting and the provision of Personal Rescue Equipment are to be raised, the necessity and benefit of which will be considered alongside issues such as the depth of the water and the height of the freeboard. We will work proactively with the WSP and the relevant landowners to identify where such measures may be implemented/improved and provide advice and assistance where we are able to do so.”

    Source location

    Response from Canal & River Trust
    Page 1 · response
    Published 3 March 2026

    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

    Direct action on public-realm water safety risks is limited because the surrounding land is not owned or controlled by the respondent.

    Verbatim wording from the response

    “As indicated in the Trust’s initial response (dated 3rd of February 2026) to your questions preceding the Inquest, the land surrounding the Shropshire Union Canal in the vicinity of the University accommodation, and crucially where Mr Webb entered the water, is not owned by the Trust. This presents a number of challenges and limits the actions we are able to take directly. Notwithstanding and following the Inquest and the concerns raised in the Regulation 28 Report (dated 26th February 2026), the Trust has taken the following actions:”

    Source location

    Response from Canal & River Trust
    Page 1 · response
    Published 3 March 2026

    Open published response
  2. Norfolk

    AI-generated summary

    Raymond Barrie Thomas MILLS · 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 17 August 2024, Raymond Barrie Thomas Mills went into the sea while viewing a shipwreck off Brancaster beach, Norfolk, and was found unresponsive; he died after being airlifted to a local airport. The concerns were that no organisation was clearly responsible for the shipwreck’s management and safety, that owners could not be identified for raising safety concerns, and that there were insufficient warnings about the dangers of the tidal waters.

    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 on-site warnings about dangers at the shipwreck

    Wider context from the report

    “3. That that wreckage does not have sufficient warnings at the location to alert members of the public, particularly those who are not familiar with the tidal waters, of the dangers present at the wreck. ”

    Source location

    Raymond Barrie Thomas MILLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Somerset

    AI-generated summary

    Peter Ivor Jeffery · 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

    Peter Ivor Jeffery, aged 68, entered the water at Burnham-on-Sea on 29 October 2023 to assist a stranger and her dog in distress and was overcome by a rip tide. He was unable to be rescued and his body was discovered near Stert Island on 12 November 2023. The report raises concerns that the risks of entering the water, including undercurrents and rip tides, were not prominently and clearly displayed to people without local knowledge, particularly outside the season when additional signage or flags were absent.

    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 prominently and clearly display water-entry risks and undercurrent and rip-tide dangers

    Wider context from the report

    “Whilst there are multiple signs in existence at the location, not all of these are for public safety, some focus on more ‘administrative’ matters such as the closure of gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly important in the smooth administration of the public space, the consequences of such are not life threatening and the size and prominence of such administrative signs and surprising when compared with the signage that conveys potentially life-saving information. I am concerned that the risks posed by entering the water (which appear equal to, if not greater than, the risks posed by the mud and sand) are not prominently and clearly displayed to those who lack local knowledge, especially out of ‘season’. This may cause people to misinterpret or underestimate the dangers posed by the undercurrent and rip-tides which, of course, are under the surface of the water and so not immediately obvious or visible. As such people may continue to make ill-advised decisions to enter the water; water which has the power and ability to overwhelm even the strongest of adult swimmers within seconds. ”

    Source location

    Peter Ivor Jeffery · 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

    Review safety signage provision at Burnham-on-Sea Jetty.

    Verbatim wording from the response

    “Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    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

    Install prominent entrance signage warning of strong currents and drowning or injury risks.

    Verbatim wording from the response

    “Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    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

    Complete lower-jetty line painting warning against access because of dangerous currents.

    Verbatim wording from the response

    “In addition, line painting is being completed on the lower part of the jetty advising against access stating “Dangerous Currents no Access””

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    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

    Install signage at the Jetty, including top-of-jetty signs and line markings on the tarmacked surface.

    Verbatim wording from the response

    “I refer to my letter dated the 11 November 2024. As discussed in my letter of the 11 November 2024 I have attached below details of the signage installed at the Jetty in Burnham on Sea. This work was completed in November 2024. This has involved signage being installed at the top of the jetty and line marked signage being applied to the tarmacked surface”

    Source location

    Updated response from Somerset Council
    Page 1 · response
    Published 19 September 2024

    Open published response
  4. Cheshire

    AI-generated summary

    Andrew James STORY · 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

    Andrew Story died after drowning while swimming in the sea in Rethymno, Crete, on holiday; a UK post-mortem also identified left ventricular hypertrophy. The report raised concerns that the sea was particularly rough, there were no lifeguards on duty, and there were no red warning markers, signs or flags to indicate the danger.

    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 red warning markers, signs or flags at the beach and sea

    Wider context from the report

    “It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season. This coincided with tourist season making the use of that beach and sea for swimming generally, and particularly unsafe in the absence of red warning markers, signs or flags ”

    Source location

    Andrew James STORY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. South Wales Central

    AI-generated summary

    Christopher Kapessa · 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 Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.

    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 signage warning of the dangers of deep and fast-flowing water

    Wider context from the report

    “(4) Inspectors were not provided with any guidance as to how to assess whether members of the public accessing the site should be safeguarded from the risks of deep and fast flowing water, and if so how. No signage was in place to warn of the specific dangers of deep and fast flowing water. No consideration was given as to whether equipment to assist in the rescue of members of the public who may have got into difficulty, such as throw lines, should be provided. ”

    Source location

    Christopher Kapessa · Prevention of Future Deaths report
    Page 3 · 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

    Implement a Water Safety Procedure guiding risk assessment and decisions on signage, fencing, information and water-rescue equipment.

    Verbatim wording from the response

    “As stated in the letter of the 17 January 2024, the CA was at that time developing a water safety procedure. This sits alongside the CA’s procedure on safe working near water. The CA’s overarching health, safety and wellbeing policy, safe working near water procedure and new Water Safety Procedure are all attached for reference.”

    Source location

    Response from Browne Jacobson
    Page 3 · response
    Published 12 February 2024

    Open published response
  6. Bedfordshire and Luton

    AI-generated summary

    Kyron Marcus HIBBERT · 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

    Kyron Marcus HIBBERT, who was unable to swim, entered the water at Stewartby Lakes from a rope swing and became submerged; his death was confirmed by paramedics on 30 July 2022. Concerns included the known use of the location and rope swing by children, limited routine checks, sudden changes in water depth without related signage, and restricted access to life-saving equipment.

    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 information about varying and sudden changes in water depth

    Wider context from the report

    “At the Inquest hearing, The Forest of Marston Vale Trust ('the Trust') stated that since Kryon's death they had taken no further action to address the risks of children drowning at Stewartby Lakes. However, it was clear from the evidence provided that: (1) The specific location where the incident occurred was well known to local children; the Head Ranger also admitted that this location, known as 'Location 5' along with 'Location 7' was known as an area where people would/could enter the water (albeit that there were signs at both locations indicating that swimming was prohibited. Furthermore, during the recent heatwave, (albeit this was not known to the Trust) local children had been regularly going to Location 5 and using a rope swing they knew to be located there ████████. (2) On Friday 29 July 2022, children had been present at the location using the rope swing since at least 20pm and yet their presence and/or the presence of the rope was not discovered ████████ - whilst Rangers do check all areas of the park, including Stewartby Lake this is only incidental to their other duties on any given day and checks are not increased around the lake during hot weather (Head Ranger's evidence); (3) At the location where the incident occurred, there are varying depths of water but (other than the general 'No Swimming' Safety Boards) there was no indication of these relative depths provided to visitors. Investigating police observed that there is a ledge of the lake that was waist height on the children (this was seen the video footage taken by the children on the day of the incident) and that this shallow ledge drops away suddenly into deep water which is believed to be 13 metres deep. It was believed that Kyron had fallen beyond the edge of the shallow area. (4) At the time of the incident, safety/life-saving equipment at the location of the incident was limited to a Safety Board consisting of a throwline in a locked box which required a code from Emergency Services (necessitating a 99 call) to release it. The Head Ranger explained that the previous life safety rings (costing approx. £40.00 each) had not been replaced once the locked throw lines had been installed. The locked throw line was not accessible to the children; although, they had seen the Safety Board as they had approached Location 5 and noted that there was some kind of float inside it, when they had gone to access it when Kyron went into the water they couldn't get the code as their phone battery had died. They reported that the box (Safety Board) "felt very far away from where we were down at the water" ████████. Although since the Inquest, the Trust have indicated that in addition to the locked throw lines on the Safety Boards, traditional safety lines are also to be installed again at Locations 5 and 7; I am concerned that these are to be placed next to the Safety Boards rather than closer to the lakeside. Whilst prompt access to further life-saving equipment may not have altered the outcome in this incident, it might in future incidents. ”

    Source location

    Kyron Marcus HIBBERT · 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

    The Trust considers its existing risk assessment and safety arrangements suitable and sufficient to address drowning risks.

    Verbatim wording from the response

    ““The Trust had a duty under Regulation 3 of the Management of Health and Safety Regulations 1999 to review its risk assessment and safety arrangements in the light of Kyron’s death. The Trust carried out this review and its conclusion was that the risk assessment in place at the time of the incident met the legal duty under Regulation 3 in that it was both suitable and sufficient. Having reviewed matters the Trust decided to continue with the roll out of the new safety boards around the lake after Kyron’s death. “”

    Source location

    Response from DAC Beachcroft
    Page 1 · response
    Published 10 March 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 no-swimming and hidden-hazard signage is considered preferable to signs identifying individual deep-water areas.

    Verbatim wording from the response

    “The Trust has not seen the video footage referred to but is aware of this issue at very many points around the lake . This is one of several reasons why entering the water is forbidden . The risk of “Hidden Hazards” is specifically identified on safety signage around the lake. As indicated in our written submission the Trust’s view is that placing signs in the very many deep water areas will create the impression that those areas that not signage are somehow safe for swimming.”

    Source location

    Response from DAC Beachcroft
    Page 2 · response
    Published 10 March 2023

    Open published response
  7. South Wales Central

    AI-generated summary

    Akeem Jevaughn RHODEN · 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

    Akeem Jevaughn Rhoden, aged 22, drowned after voluntarily jumping from a rock into the water at Sgwd y Pannwr Waterfall on 5 June 2021; he was not a strong swimmer and his body was recovered the following day. The concerns raised were that warning signs at waterfalls in Waterfall Country were inadequate, absent at the point where he entered the water, overloaded with information, and did not clearly explain the danger posed by the force of the water.

    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 provide adequate warning signage at points where individuals may decide to enter the water

    Wider context from the report

    “(1) The signage at ALL waterfalls in ‘Waterfall Country’ must be addressed; (2) Akeem Roden was not a strong swimmer and there were no adequate signs at the point he jumped in to warn him of the potential dangers and that he might drown; (3) Signage at each waterfall should be in plain, bold, easily understandable English, spelling out the danger of the power of the water; (4) Existing signage is overloaded with information and not present at the point where individuals may decide to enter the water. ”

    Source location

    Akeem Jevaughn RHODEN · 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 of waterfall signage to provide clear, concise warnings about the power and dangers of the water

    Wider context from the report

    “(1) The signage at ALL waterfalls in ‘Waterfall Country’ must be addressed; (2) Akeem Roden was not a strong swimmer and there were no adequate signs at the point he jumped in to warn him of the potential dangers and that he might drown; (3) Signage at each waterfall should be in plain, bold, easily understandable English, spelling out the danger of the power of the water; (4) Existing signage is overloaded with information and not present at the point where individuals may decide to enter the water. ”

    Source location

    Akeem Jevaughn RHODEN · 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

    Complete independent and high-volume-area reviews of existing signage and identify necessary safety improvements.

    Verbatim wording from the response

    “Consequently, signage is something we must consider very carefully in the context of a natural landscape. We will seek to respond to the key point of signage that has been raised by the Coroner’s concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the site by undertaking a signage review and implementing any necessary actions.”

    Source location

    Response from Neath Port Talbot Council
    Page 2 · response
    Published 4 January 2023

    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

    Implement a uniform signage approach arising from the signage review.

    Verbatim wording from the response

    “Consequently, signage is something we must consider very carefully in the context of a natural landscape. We will seek to respond to the key point of signage that has been raised by the Coroner’s concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the site by undertaking a signage review and implementing any necessary actions.”

    Source location

    Response from Neath Port Talbot Council
    Page 2 · response
    Published 4 January 2023

    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

    Put temporary warning signs in place at the site.

    Verbatim wording from the response

    “Coroner’s Matters of Concern | Response | Action already completed | Action proposed The signage at all waterfalls in Waterfall Country must be addressed | We agree with using signs that are clear to all users regardless of language. It should be noted that each authority must also comply with Welsh Language Standards which does require additional information to be present. | We have instructed an independent reviewer to advise on the formation and content of new signs and temporary signs are being put in place to warn of concerns. | To review signage and implement a uniform form of signage.”

    Source location

    Response from Neath Port Talbot Council
    Page 3 · response
    Published 4 January 2023

    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

    Erect signs advising visitors about unpredictable water flow.

    Verbatim wording from the response

    “• Signs will be erected to advise individuals of unpredictable water flow. Advice has suggested to date the Council should refrain from using any words such as Danger, Caution or Warning as it indicates a problem, and indeed Deep Water as someone will no doubt dive in when it is shallow.”

    Source location

    Response from Neath Port Talbot Council
    Page 5 · response
    Published 4 January 2023

    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

    Commission an independent expert report on visitor safety management, including signage, in Waterfall Country.

    Verbatim wording from the response

    “1.1. Natural Resources Wales is in the process of commissioning a report from an independent expert concerning visitor safety management to include signage in Waterfall Country. The outcome of this process will be shared with Brecon Beacons National Park Authority, Powys County Council, Rhondda Cynon Taf and Neath Port Talbot Council.”

    Source location

    Response from Natural Resources Wales
    Page 1 · response
    Published 4 January 2023

    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

    Review the independent expert's report on visitor safety management and signage.

    Verbatim wording from the response

    “1.2. Brecon Beacons National Park Authority will review the independent report and reposition its signage as reasonably required having considered the recommendations of the report.”

    Source location

    Response from Natural Resources Wales
    Page 1 · response
    Published 4 January 2023

    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

    Erect semi-permanent safety signs at the specified Waterfall Country locations.

    Verbatim wording from the response

    “Pending the report of the independent expert, semi-permanent signs are being erected at the following locations in Waterfall Country. NRW will mark their signs as marked on the plan (numbers 1-8) and Brecon Beacons National Park Authority (numbers 9-16) Enclosure 1 and set out below:”

    Source location

    Response from Natural Resources Wales
    Page 2 · response
    Published 4 January 2023

    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

    Use Visitor Safety Group Communicating Safety Guidance when designing Waterfall Country safety signs.

    Verbatim wording from the response

    “The signs that are being erected in Waterfall Country, have been designed with reference to the Visitor Safety Group Communicating Safety Guidance an extract of which is set out below:”

    Source location

    Response from Natural Resources Wales
    Page 3 · response
    Published 4 January 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

    Welsh Language Standards require additional information on signs, limiting the use of signage consisting solely of clear plain-language safety warnings.

    Verbatim wording from the response

    “Coroner’s Matters of Concern | Response | Action already completed | Action proposed The signage at all waterfalls in Waterfall Country must be addressed | We agree with using signs that are clear to all users regardless of language. It should be noted that each authority must also comply with Welsh Language Standards which does require additional information to be present. | We have instructed an independent reviewer to advise on the formation and content of new signs and temporary signs are being put in place to warn of concerns. | To review signage and implement a uniform form of signage.”

    Source location

    Response from Neath Port Talbot Council
    Page 3 · response
    Published 4 January 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

    Advice recommends refraining from terms such as Danger, Caution, Warning and Deep Water when erecting signs.

    Verbatim wording from the response

    “• Signs will be erected to advise individuals of unpredictable water flow. Advice has suggested to date the Council should refrain from using any words such as Danger, Caution or Warning as it indicates a problem, and indeed Deep Water as someone will no doubt dive in when it is shallow.”

    Source location

    Response from Neath Port Talbot Council
    Page 5 · response
    Published 4 January 2023

    Open published response
  8. South Wales Central

    AI-generated summary

    Hemanta Kumar Rai · 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

    Hemanta Kumar Rai, aged 28, drowned in August 2021 after a strong current pulled him underwater towards a waterfall while he was visiting South Wales. The concerns were inadequate and unclear signage warning of the risk of death by drowning, and uncertainty about responsibility for the area.

    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 provide adequate, clear signage warning of the risk of death by drowning

    Wider context from the report

    “(1) There is no adequate signage to warn visitors of the risk of drowning by entering the water at Sgwd Gwladys. (2) Existing signage in “Waterfall Country” is overloaded with a variety of information, which although helpful for walking routes etc, is not explicit in warning of the real danger of death from entering the water. (3) Any sign(s) erected ought to be easily visible, in plain English and spell out the risk of death by drowning. ”

    Source location

    Hemanta Kumar Rai · 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

    Complete an independent review of signage at the Site and public-access areas on respondent-owned land.

    Verbatim wording from the response

    “2.2. We will seek to respond to the key point of signage that has been raised by the Coroner’s concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the Site by undertaking a signage review and implementing any necessary actions (see section Error! Reference source not found.).”

    Source location

    Response from Neath Port Talbot Council
    Page 3 · response
    Published 29 September 2022

    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

    Review signs in high-volume visitor areas to ensure they are fit for purpose and uniform in design, content and application.

    Verbatim wording from the response

    “5.2. In the interim, Brecon Beacons National Park Authority has commissioned a review of all signs within its high-volume visitor areas to ensure they are fit for purpose and are uniform in their design, content and application.”

    Source location

    Response from Neath Port Talbot Council
    Page 3 · response
    Published 29 September 2022

    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

    Implement necessary signage changes identified through the review to provide a uniform approach.

    Verbatim wording from the response

    “2.2. We will seek to respond to the key point of signage that has been raised by the Coroner’s concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the Site by undertaking a signage review and implementing any necessary actions (see section Error! Reference source not found.).”

    Source location

    Response from Neath Port Talbot Council
    Page 3 · response
    Published 29 September 2022

    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

    Conduct independent reviews of signage at the Site and in high-volume visitor areas, including a scheduled safety-consultant site visit.

    Verbatim wording from the response

    “4.1. As a result of the concerns that the Coroner raised in her report, Brecon Beacons National Park Authority has commissioned an independent review of signage at the Site and a Site visit has been scheduled for 29th September 2022 which is to be led by the external health and safety consultant and attended by officers from Brecon Beacons National Park Authority, Neath Port Talbot Council and Natural Resources Wales.”

    Source location

    Response from Brecon Beacons National Park
    Page 3 · response
    Published 29 September 2022

    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

    Review signage across the National Park and Neath Port Talbot Council land and implement a uniform signage approach where necessary.

    Verbatim wording from the response

    “2.2. We will seek to respond to the key point of signage that has been raised by the Coroner's concerns, and to identify any changes to signage to mitigate the risk of any future death by accident by someone visiting the Site by undertaking a signage review and implementing any necessary actions (see section Error! Reference source not found.).”

    Source location

    Response from Brecon Beacons National Park
    Page 2 · response
    Published 29 September 2022

    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 area concerned is outside both authorities’ ownership, so they do not undertake signage work there.

    Verbatim wording from the response

    “(1) There is no adequate signage to warn visitors of the risk of drowning by entering the water at Sgwd Gwladys. | This area is not within the ownership of Brecon Beacons National Park Authority or Neath Port Talbot Council. | We have instructed an independent reviewer to compile a complete review of signage within public access areas within our land ownership | To review signage within the National Park and land in the ownership of Neath Port Talbot Council and consider implementing a uniform form of signage.”

    Source location

    Response from Neath Port Talbot Council
    Page 4 · response
    Published 29 September 2022

    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 area lacking adequate drowning-warning signage is outside both authorities’ ownership and therefore their direct remit.

    Verbatim wording from the response

    “(1) There is no adequate signage to warn visitors of the risk of drowning by entering the water at Sgwd Gwladys. | This area is not within the ownership of Brecon Beacons National Park Authority or Neath Port Talbot Council. | We have instructed an independent reviewer to compile a complete review of signage within public access areas within our land ownership | To review signage within the National Park and land in the ownership of Neath Port Talbot Council and consider implementing a uniform form of signage.”

    Source location

    Response from Brecon Beacons National Park
    Page 4 · response
    Published 29 September 2022

    Open published response
  9. North Yorkshire (Western)

    AI-generated summary

    MOHAMMED BILAL ZEB · 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

    MOHAMMED BILAL ZEB, aged 18, drowned after jumping into the River Wharfe at Linton Falls on 31 July 2020; he could not swim and became unresponsive. Concerns included the absence of flotation or rescue aids, difficult access and conditions for rescuers, and a lack of apparent safety warnings about hazards including cold water, water flow and underwater obstructions.

    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 safety warnings about unseen cold-water and water-flow hazards

    Wider context from the report

    “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident. (2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties. It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location. (3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels. ”

    Source location

    MOHAMMED BILAL ZEB · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Essex

    AI-generated summary

    Malika Shammas and Haider Ali · 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

    Malika Shammas and Haider Ali got into difficulties while bathing in the sea near a groyne at Clacton-on-Sea on 8 August 2019 and both died. The substantive concerns included inadequate or difficult-to-read signage, limited beach surveillance, and whether greater liaison with the RNLI could improve beach 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 warning notices by the pier

    Wider context from the report

    “3. Mindful that there had been a previous teenage drowning fatality at Clacton beach near the pier, warning notices by the pier might assist. ”

    Source location

    Malika Shammas and Haider Ali · 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 groyne danger signage to remain legible

    Wider context from the report

    “2. The Danger sign by the relevant groyne was difficult to read. The wording and layout could be improved and maybe such notices by each groyne would assist. There was vivid evidence from the young victims’ mother of the swirling nature of the currents around the relevant groyne ”

    Source location

    Malika Shammas and Haider Ali · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026