Recurring concern

Unclear allocation of safety responsibilities at organised public events

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First reported 25 Nov 2021•Latest report 10 Apr 2025

Definition

What this concern includes

Includes failures in arrangements for assigning, clarifying, documenting, communicating or coordinating safety responsibilities between event organisers, venues, contractors and other event safety functions at organised public events, including the anchor’s provider-to-provider responsibility distinction and unclear responsibility for safety measures at organised open-water swimming events.

Not included

  • Excludes generic organisational accountability or communication failures that are not tied to safety responsibilities at an organised public event.
  • Excludes failures of emergency response, first aid, crowd control, participant monitoring or water safety where responsibility allocation is clear and the deficient control is elsewhere.
  • Excludes regulatory oversight or licensing deficiencies that do not concern assignment or communication of operational safety responsibilities.
  • Excludes ordinary role descriptions or disagreements without an identified continuing risk that event safety responsibilities are unclear or unowned.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2021–2025

First to latest report issue date

Stated actions
0

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.

Bounce Til I Die1
Department for Digital, Culture, Media and Sport1
Health and Safety Executive1
Home Office1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Sunderland

    AI-generated summary

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unclear responsibility for safety measures at organised open water swimming events

    Wider context from the report

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

    Source location

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

    Open source report

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Laura Amy Smallwood · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source location

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

    Open source report

  3. Newcastle upon Tyne

    AI-generated summary

    Neil James STEWART · 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

    Neil James Stewart travelled to Amsterdam in November 2017 and, on 18 November 2017, entered the Noordzeekanaal after jumping from a party boat; his body was recovered on 3 December 2017. The concerns addressed written safety policies and warnings for guests, venue-specific risks, and clarity about safety responsibilities between entertainment providers and venue organisers.

    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 document the division of safety responsibilities with another provider

    Wider context from the report

    “(3) When providing entertainment services in venue where another provider is responsible for organisation, safety of guests – discuss with the provider the details and clearly document the distinction in those responsibilities and give guidance to guests accordingly ”

    Source location

    Neil James STEWART · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026