Recurring concern

Inadequate surveillance of swimmers and water users

First to latest report 13 Aug 2018 — 27 Feb 2023

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
1

What this concern includes

Includes dedicated beach or waterside surveillance arrangements for swimmers and other water users, including patrol positioning, observation coverage, watching systems and comparable controls intended to detect incidents or people in difficulty promptly.

What is not included
  • Excludes general lifeguard staffing or beach-cover shortages where surveillance coverage or detection is not the identified unsafe condition.
  • Excludes CCTV, lighting or rescue-equipment deficiencies where the assertion does not concern surveillance or detection of swimmers and water users.
  • Excludes the underlying presence of dangerous currents, rough water or other beach hazards where no surveillance deficiency is identified.
  • Excludes emergency rescue or treatment failures occurring after an incident has been reliably detected.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. 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

    Insufficient surveillance of lake areas and visitor hazards

    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

    The lake’s size, topography and restricted sight lines make routine visual checks impracticable and ineffective.

    Verbatim wording from the response

    “The sheer size ,topography and restricted sight lines render routine visual checks impracticable and ineffective.”

    Source location

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

    Open published response

  2. 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

    Inadequate beach patrol surveillance coverage

    Wider context from the report

    “5. The beach patrol officer was 395 metres away from the fatality incident and was unable even with the use of binoculars to discern the nature of the incident.. More extensive surveillance would help on such a busy stretch of beach. ”

    Source location

    Malika Shammas and Haider Ali · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner West London

    AI-generated summary

    Henry Huw Duncan Campbell · 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

    Henry Huw Duncan Campbell drowned after failing to resurface while free-diving in deep seawater off Zakynthos, Greece, on 6 August 2017. The report raised concerns about the availability of deep-water rescue equipment, watchtower manning records, and monitoring of swimmers as well as sea-craft.

    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

    Inadequate watching system for swimmers and sea-craft

    Wider context from the report

    “4. That an appropriate watching system for swimmers as well as sea-craft be put in place. ”

    Source location

    Henry Huw Duncan Campbell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. 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 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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026