Recurring concern

Inadequate individual risk assessment for activities

First to latest report 4 Feb 2014 — 10 Apr 2025

Reports that mention this concern
8
Times this concern has been raised
9
Stated actions linked to this concern
8

What this concern includes

Includes failures of controls specifically dedicated to assessing individual participants before an activity, including obtaining relevant medical or personal risk information, evaluating suitability, and communicating the resulting information to activity leaders or providers.

What is not included
  • Excludes generic activity risk assessments that do not concern individual participant risks or suitability.
  • Excludes generic information-sharing, liaison, training or documentation deficiencies unless they directly impair individual activity-risk assessment.
  • Excludes failures limited to assessing the physical venue, equipment or emergency arrangements where no individual participant assessment is involved.
  • Excludes post-activity incidents or outcomes where no deficiency in pre-activity individual risk assessment is identified.

Reports and published responses 8 reports

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

  1. Sunderland

    AI-generated summary

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of knowledge of participant competency and capability

    Wider context from the report

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

    Source location

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Dorset

    AI-generated summary

    Iain Richard Farrell · 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

    Iain Richard Farrell became breathless and exhausted during a led coasteering activity on 26 May 2019, was swept back into the sea by a large wave after reaching a ledge, and was later confirmed deceased despite resuscitation efforts. The principal concerns were the risks of lone guiding, the delayed access to the sole means of communication, and the absence of assessment of participants’ swimming ability and physical fitness during booking.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to assess prospective participants’ swimming ability and physical fitness during coasteering booking

    Wider context from the report

    “iv. At the time of booking a coasteering experience, the nature and potential physical demands of the experience at the coasteering location proposed should be made clear and a prospective participant should be asked about their swimming ability and physical fitness. ”

    Source location

    Iain Richard Farrell · 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

    Produce a final updated Safety Advice for Coasteering Providers document incorporating consultation responses and advice.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from National Coasteering Charter
    Page 1 · response
    Published 1 November 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

    Consult NCC members by email and through a committee-led working group on updates to the Safety Advice for Coasteering Providers document.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from NCC
    Page 1 · response
    Published 1 November 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

    Produce a final updated Safety Advice for Coasteering Providers document incorporating member consultation responses and advice.

    Verbatim wording from the response

    “The current NCC document, ‘Safety Advice for Coasteering Providers 2015 Version 3’ will be updated to address the 4 points raised as concerns by the Coroner in Section 5.2 i-iv in the Prevention of Future Deaths report. The rewrite will also update the 2015 version with other practices and advice that may have changed since the writing of the original advice with an aim of continuing to promote safe coasteering.”

    Source location

    Response from NCC
    Page 1 · response
    Published 1 November 2023

    Open published response

  3. Gloucestershire

    AI-generated summary

    Richard Paul Victor Sanders · 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

    Richard Sanders, an experienced diver aged 52, became unresponsive during a dive to 45 metres on 11 April 2019 and was pronounced deceased at the scene. The concerns included awareness of immersion pulmonary oedema risks, the need for fitness-to-dive medical certification, and methods for removing divers from 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 give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation

    Wider context from the report

    “2. Whether sufficient consideration has been given to the requirement for a “fitness to dive” medical certificate as a prerequisite to participation in diving activities. ”

    Source location

    Richard Paul Victor Sanders · 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

    Consider new information affecting fitness-to-dive guidance at each committee meeting.

    Verbatim wording from the response

    “The UKDMC sets the medical requirements for diving for several national amateur diving organisations in the UK. Its members also advise the Health and Safety Executive on the medical requirements for commercial diving. The committee meets about 4 times per year and at every meeting it considers new information that might affect our guidance on fitness to dive.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    Require health declarations to identify IPO and other health factors influencing IPO risk before referral for medical advice or physical examination.

    Verbatim wording from the response

    “The UKDMC fitness assessment depends on a health declaration which determines whether a UKDMC Medical Referee (who will have received updates on IPO and its known risk factors) should be approached for advice or a physical examination. The health declaration asks specifically about IPO and also asks about other aspects of health which can influence risk of IPO. Routine annual physical examination has not been required for many years as it added no benefit to the assessment of those who did not declare any problems. Many divers have not declared problems, sometimes leading to fatality, but re-introduction of routine physical examination would not capture those who choose to dive independently and, due to lack of a specific test for susceptibility to IPO, would still miss individuals at risk.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    Update recreational diving medical questionnaires to include specific screening questions or references concerning immersion pulmonary oedema.

    Verbatim wording from the response

    “Given that physical health is an important factor when diving, the two medical assessment forms have been updated in the past 2-3 years to include sections specifically to screen for a person’s susceptibility to IPO.”

    Source location

    2022-0003-Response-from-British-Diving-Safety-Group_Published
    Page 2 · response
    Published 10 January 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 existing health declaration and referral process is considered sufficient; routine annual physical examinations add no benefit for those declaring no problems.

    Verbatim wording from the response

    “The UKDMC fitness assessment depends on a health declaration which determines whether a UKDMC Medical Referee (who will have received updates on IPO and its known risk factors) should be approached for advice or a physical examination. The health declaration asks specifically about IPO and also asks about other aspects of health which can influence risk of IPO. Routine annual physical examination has not been required for many years as it added no benefit to the assessment of those who did not declare any problems. Many divers have not declared problems, sometimes leading to fatality, but re-introduction of routine physical examination would not capture those who choose to dive independently and, due to lack of a specific test for susceptibility to IPO, would still miss individuals at risk.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    Reintroducing routine physical examinations would not identify independently diving people or those at risk because no specific test for IPO susceptibility exists.

    Verbatim wording from the response

    “Unlike flying, vocational driving or commercial diving, there is no legal requirement to have a medical examination for recreational diving. As a result, although some organisations insist that people diving with them satisfy the UKDMC requirements, people can dive independently without any medical examination.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    Reducing dishonest health declarations remains difficult because access to general practitioner records has proved unhelpful in some cases.

    Verbatim wording from the response

    “We do not condone dishonest declarations, not least because such behaviour endangers the diver’s buddy. We have considered ways that we can reduce dishonest declaration but even access to General Practitioner records has been unhelpful in some cases. This situation is not unique to diving. For instance, applicants make false medical declarations about eyesight, blackouts etc in order to retain a driving licence.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    A medical certificate requirement based on IPO risk is considered justifiable only if an equivalent requirement applies to open-water swimming.

    Verbatim wording from the response

    “Finally, more cases of IPO occur during open water swimming than in divers each year because there are more open water swimmers than divers. As a result, we believe that a requirement for a medical certificate for diving based on the risk of IPO could only be reasonably justified if the same was required for open water swimming.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 2 · response
    Published 10 January 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

    Responsibility for current diving-operation safety arrangements lies with DTSL, the new operator, which should be contacted for further information.

    Verbatim wording from the response

    “Until 23 December 2021, the Diving Centre was operated by N.D.A.C. Limited (NDAC) at Dayhouse Quarry (also known as Tidenham Quarry). However, in connection with the sale of Dayhouse Quarry to a third party, NDAC’s rights to operate the Diving Centre at the quarry were terminated as from 23 December 2021.”

    Source location

    2022-0003-Response-from-National-Diving-Activity-Centre_Published-1
    Page 1 · response
    Published 10 January 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

    Existing self-declaration questionnaires and referral arrangements are considered sufficient; a fitness-to-dive medical certificate is not required before participation.

    Verbatim wording from the response

    “Current arrangements: All the significant training agencies and the sports’ governing body, use one of two self-guided questionnaires to screen for medical conditions which require referral to a Diving Medical Referee for consultation and advice e.g. epileptics requiring medication or diabetics with recent hypoglycaemia are advised not to dive because of the risk of unexpected loss of consciousness which could be fatal underwater.”

    Source location

    2022-0003-Response-from-British-Diving-Safety-Group_Published
    Page 6 · response
    Published 10 January 2022

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Joshua Hoole · 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

    Joshua Hoole collapsed and died during an 8-mile, 25 kg loaded march as part of an annual fitness test at Dering Lines Barracks on 19 July 2016. He showed signs of heat illness before collapsing, and was declared deceased despite emergency treatment. The principal concerns included inadequate training and understanding of heat-illness guidance, failure to check or correctly measure the Wet Bulb Globe Temperature, inadequate communication about heat-illness cases, and failure to stop the activity when students became unwell.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a system to provide individual risk information for activity risk assessments

    Wider context from the report

    “6. Individual risk factors were an important part of understanding how a soldier would react to a situation and how best to mitigate any associated risk. At present there is no clear system in place to ensure those conducting activities have the necessary information about an individual to enable them to carry out an appropriate risk assessment. ”

    Source location

    Joshua Hoole · 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

    Add an individual-factor checklist and heat-illness risk-assessment direction to the new Army heat-illness prevention order.

    Verbatim wording from the response

    “JSP 539 includes guidance on the individual factors to be considered in relation to heat. The new ACSO 3222 Army Heat Illness Prevention, will provide additional direction specific to Army requirements. This will include a checklist of individual factors for use by commanders prior to the activity, and specific reference to heat illness risk assessments (Annex C to ACSO 3222).”

    Source location

    2019-0458-Response-by-MOD
    Page 5 · response
    Published 2 January 2020

    Open published response

  5. Northamptonshire

    AI-generated summary

    Andrea McHugh · 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

    Andrea McHugh, who had epilepsy and continued to experience seizures after brain surgery, died after being found floating in the sea while snorkelling during a boat trip in Cuba on 17 June 2016. The report raised concerns that the participant waiver did not mention the dangers of swimming in the sea for people with epilepsy and did not request participants’ past medical history.

    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 participant waivers to request participants' past medical history

    Wider context from the report

    “1) Marinas Gaviota S.A allegedly require participants in the boat and snorkelling trip to sign a waiver. (copy attached). The waiver does not mention the dangers of swimming in the sea if a participant suffers from epilepsy. 2) Additionally the waiver does not request details of participants past medical history. ”

    Source location

    Andrea McHugh · 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

    Review whether to request further waiver amendments covering medical history that may make sea excursions dangerous.

    Verbatim wording from the response

    “Thomas Cook then intends to review whether we request Gaviota make further amendment to their waiver to include reference to any medical history that may make it dangerous for our customers to go in to the sea and therefore should be included in the waiver. If further amendment is required it is envisaged that it will be necessary for Thomas Cook to obtain expert medical advice in respect of this to ensure appropriate relevant medical history is included.”

    Source location

    2018-0060-Response-by-Thomas-Cook
    Page 1 · response
    Published 8 June 2018

    Open published response

  6. Inner South London

    AI-generated summary

    Master Abdul-Jamal Ottun · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate pre-assessment of swimming ability before outdoor swimming activities

    Wider context from the report

    “He said that child deaths will continue to occur unless there is a fundamental change in the curriculum and in the pre-assessment of swimming ability before school trips and occasions when swimming outdoors. In this case, parents indicated on a form the swimming ability of their children in one of three boxes (strong/ moderate/ weak) This he said was wholly inadequate, as they often have no accurate idea of the adequacy of their children’s swimming. ”

    Source location

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

    Open source report

  7. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Lomas · 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

    John Lomas, a serving soldier, died after a white water rafting boat capsized shortly after launch on the River Inn on 21 June 2012; he was unable to be resuscitated and was certified dead. Concerns included inadequate liaison and risk assessment, the raft exceeding its permitted capacity for the prevailing conditions, launching too close to a stopper, and the absence of preparatory training, a water confidence test, and a safety kayak.

    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 generic risk assessment for soldier suitability for rafting

    Wider context from the report

    “1. There had been no liaison between Sport Camp Tirol and the Army prior to the white water rafting Trip that took place on the 21st June 2012. No generic risk assessment had been provided to or requested by Sports Camp Tirol as a result there was a lack of understanding as to the suitability of soldiers to undertake the trip. ”

    Source location

    John Lomas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. South London

    AI-generated summary

    Samuel Boon · 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

    Samuel Boon, aged 17, collapsed from suspected exertional heatstroke and/or hyponatremia while trekking in high temperatures on a school trip in Morocco and died during a 25-minute journey to a local medical centre. Concerns included inadequate preparation and risk assessment, insufficient assessment of participants’ fitness and medical information, inadequate training about heatstroke and hyponatremia, and evacuation arrangements that had not been adequately assessed or equipped.

    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 proactively obtain up-to-date participant medical information before departure

    Wider context from the report

    “(1) Preparation • The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained. • Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency. • Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved. • Up to date medical information about the participants was not proactively obtained shortly before departure. Evacuation: • Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible. • Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred. • Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny. NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely. ”

    Source location

    Samuel Boon · Prevention of Future Deaths report
    Page 3 · 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 formally assess individual participants’ fitness for the activity

    Wider context from the report

    “(1) Preparation • The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained. • Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency. • Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved. • Up to date medical information about the participants was not proactively obtained shortly before departure. Evacuation: • Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible. • Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred. • Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny. NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely. ”

    Source location

    Samuel Boon · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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