Recurring concern

Unreliable lifeguard provision for aquatic safety

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First reported 5 Feb 2014•Latest report 4 Jun 2025

Definition

What this concern includes

Includes failures of the dedicated lifeguard provision function, including lifeguard availability, staffing coverage, medical or first-aid competence, deployment during higher-risk periods, and requirements or arrangements intended to ensure effective lifeguard safety coverage at beaches, pools and comparable aquatic venues.

Not included

  • Excludes generic staff shortages, training deficiencies or emergency-response failures not specifically tied to lifeguard provision for aquatic safety.
  • Excludes general drowning-risk controls, rescue equipment or warning signs when no lifeguard-provision deficiency is identified.
  • Excludes clinical or first-aid competence concerns involving staff who are not responsible for lifeguarding.
  • Excludes ordinary beach or swimming-pool hazards where lifeguard coverage is not the reported unsafe condition.
Reports
11

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
9

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.

Royal National Lifeboat Institution4
Maritime and Coastguard Agency3
ABTA Ltd2
Department for Transport2
Associated British Ports1
Cabinet Office1
Embassy of Italy in London1
Foreign, Commonwealth & Development Office1
Institution of Occupational Safety and Health1
Neath Port Talbot County Borough Council1
Relevant Greek authorities1
Royal Life Saving Society UK1
The Chartered Institute of Environmental Health1

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. Swansea and Neath Port Talbot

    AI-generated summary

    DAVID CHIAKA EJIMOFOR · 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

    DAVID CHIAKA EJIMOFOR, aged 15, drowned after jumping into the sea from a breakwater at Aberavon on 19 June 2023. The principal concerns were the absence of lifeguards during higher-risk periods, despite their historical use to deter jumping, and the lack of evidence that alternative deterrence measures were effective.

    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 lifeguard cover at the breakwater during higher-risk spring and summer periods

    Wider context from the report

    “(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it. (2) Jumping from, and the water around, the breakwater is known to be dangerous. (3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk. (4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today. (5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk. ”

    Source location

    DAVID CHIAKA EJIMOFOR · 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 the beach safety assessment and decide lifeguard deployment for the 2026 summer season using monitoring findings.

    Verbatim wording from the response

    “As noted above, the RNLI is currently undertaking an exercise to monitor activity in the vicinity of the breakwater. These monitoring efforts and discussions are expected to continue across the summer 2025, to help inform a formal review of the Beach safety assessment and in turn a decision regarding lifeguard deployment for the 2026 summer season. Should it ultimately be determined that additional lifeguard coverage is necessary, NPTCBC’s intention would be to implement this provision during 2026 subject to the necessary funding being available.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 3 · response
    Published 11 June 2025

    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

    There is no evidence that breakwater risk has worsened, and the deceased accessed it outside historical lifeguard operating hours.

    Verbatim wording from the response

    “The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months had been in place historically and was known to be effective at reducing the risk.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 3 · response
    Published 11 June 2025

    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 council cannot police access to the breakwater because it is third-party-owned land outside the council’s ownership or control.

    Verbatim wording from the response

    “NPTCBC cannot police access to the breakwater, whether by lifeguard provision or otherwise. The breakwater is outside NPTCBC’s ownership.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 2 · response
    Published 11 June 2025

    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

    Lifeguarding provision on the breakwater is addressed through RNLI recommendations and ABP’s engagement as landowner.

    Verbatim wording from the response

    “NPTCBC will continue its dialogue with RNLI in particular but also with ABP. NPTCBC will be led by RNLI’s recommendations in view of their nationally recognised expertise and will continue to address recommendations as far as is practicable within resource and budgetary constraints. ABP’s engagement with RNLI as to provision of services on the breakwater itself is beyond NPTCBC’s knowledge.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 2 · response
    Published 11 June 2025

    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

    If RNLI’s current assessment recommends no changes, existing beachfront lifeguarding provision will continue under those recommendations.

    Verbatim wording from the response

    “The current Beach safety assessments continue to recommend services along the Aberavon beach front area encouraging and instructing the public to swim at lifeguarded areas and during lifeguarded times. NPTCBC awaits the outcome of RNLI’s current monitoring and risk assessment period following which, if recommended, changes in service along the beachfront area will be implemented. If there are no changes implemented NPTCBC will continue to provide the lifeguarding provision in line with the current RNLI recommendations.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 4 · response
    Published 11 June 2025

    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

    Any additional lifeguard coverage depends on necessary funding being available.

    Verbatim wording from the response

    “As noted above, the RNLI is currently undertaking an exercise to monitor activity in the vicinity of the breakwater. These monitoring efforts and discussions are expected to continue across the summer 2025, to help inform a formal review of the Beach safety assessment and in turn a decision regarding lifeguard deployment for the 2026 summer season. Should it ultimately be determined that additional lifeguard coverage is necessary, NPTCBC’s intention would be to implement this provision during 2026 subject to the necessary funding being available.”

    Source location

    Response from NEATH PORT TALBOT COUNCIL
    Page 3 · response
    Published 11 June 2025

    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

    Lifeguarding cannot be provided without the landowner’s request or consent, and the RNLI has no contract with the breakwater owner.

    Verbatim wording from the response

    “As set out at the inquest, although the RNLI chooses to provide lifeguarding services, it has no legal duty to do so. Importantly, it cannot provide any service without the landowners or the occupier’s request or consent. It is entirely a matter for the landowner or occupier whether they ask and contract with the RNLI to provide a lifeguarding service.”

    Source location

    Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
    Page 1 · response
    Published 11 June 2025

    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

    Preventing access to water should be undertaken by security guards or wardens rather than lifeguards deployed to facilitate bathing.

    Verbatim wording from the response

    “Lifeguards are normally deployed to facilitate bathing rather than preventing aquatic activities. If solely deployed to stop access it would be more appropriate to deploy a security guard or warden service.”

    Source location

    Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
    Page 3 · response
    Published 11 June 2025

    Open published response
  2. 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

    Lack of lifeguards on duty during the summer season

    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
  3. Cornwall and Isles of Scilly

    AI-generated summary

    Michael Pender and 2 others · 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

    Michael Pender, Jan Klempar and Paul Mullen drowned at beaches in Cornwall during summer 2020 after entering difficulty in the sea; the beaches would ordinarily have had lifeguards, but none were present at the relevant times following the easing of COVID-19 lockdown restrictions. The principal concerns were difficulties in recruiting and preparing seasonal lifeguards, lack of advance notice to the RNLI about the relaxation of lockdown, difficulties sourcing PPE, and wider uncertainty about responsibility for beach-safety policy and the provision of lifeguards.

    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

    Unavailability of seasonal lifeguards during periods of required beach safety coverage

    Wider context from the report

    “i) The government took the decision to offer furlough to those in receipt of PAYE as at the end of February 2020. Most of the c1600 lifeguards who work on the 250 beaches where the RNLI are present are seasonal employees. They did not qualify for furlough. At that point in time, the RNLI was in the process or recruiting and training the seasonal lifeguards it required. When furlough was not offered, a number had to seek alternative means of income. As lockdown was eased and lifeguards were required, the RNLI did not have immediately available to it the seasonal employees it required to provide beach safety around the coast. I found this contributed to the problems that ensued in a partial sense. I do not suggest that had the seasonal lifeguards been furloughed all of the difficulties could have been avoided. The evidence revealed some lifeguards may not have wanted to take up their position in light of COVID and there were additional complications like how new lifeguards became formally qualified when providers were not available as well as how the RNLI could have provided COVID secure places of work in the time available; ”

    Source location

    Michael Pender and 2 others · 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

    Lack of clear legal duties for beach safety and lifeguard provision

    Wider context from the report

    “In 2016, seven men drowned at Camber Sands in East Sussex. My colleague, HM Senior Coroner Mr Craze, wrote a series of PFDs. This led to the publication by the MCA of previously lacking guidance for landowners and local authorities on how to manage beach safety and is to be welcomed. The MCA also commissioned from DWF a report reviewing legal responsibilities for beach safety that was available in January 2019 but not published until November 2020. It identified a confused and conflicting legal landscape where there was no clear legal duty to provide lifeguards and most owners/occupiers were acting out of social conscience than for any other reason. All stakeholders wanted greater clarity to be introduced. That has not happened and there has been no formal government response to the review. Indeed, it appears as though there is no government department that has responsibility for the area. In a letter from the Secretary of State for Transport, Mr Harper, to me I was informed: Neither the MCA, nor the Department for Transport (DfT), has any wider responsibilities for beach safety policy or legislation. This may provide an explanation for why this concern has remained for so long. As long ago as 2006, a local MP observed that it was a ‘ridiculous anomaly’ that there was more regulation for swimming in a public pool than there was for swimming in the more dangerous environment of the sea, or that there were stricter standards for working on a vessel at sea than there were for members of the public going to the coast. ”

    Source location

    Michael Pender and 2 others · 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

    Share concerns about RNLI lifeguard furlough eligibility with HM Treasury and HM Revenue and Customs.

    Verbatim wording from the response

    “○ On the issue of the RNLI lifeguards not being eligible for furlough, we have shared your concerns with HMT and HMRC given their oversight of the policy, which they have acknowledged receipt of. Covid economic support schemes, including the Coronavirus Job Retention Scheme, are being examined in Module 9 of the Inquiry, and we await the Inquiry’s recommendations on this issue;”

    Source location

    Response from Cabinet Office
    Page 1 · response
    Published 12 February 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

    Consider beach safety policy, including clarity about landowners’ and occupiers’ duties and departmental responsibility.

    Verbatim wording from the response

    “I note your concerns in relation to beach safety policy more generally, including the calls for greater clarity for landowners and occupiers on their duties, and the lack of clear departmental responsibility within government. Government is currently considering these issues and we would be happy to provide your office with an update as this progresses.”

    Source location

    Response from Cabinet Office
    Page 2 · response
    Published 12 February 2024

    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

    HMT and HMRC oversee the policy concerning RNLI lifeguard eligibility for furlough.

    Verbatim wording from the response

    “○ On the issue of the RNLI lifeguards not being eligible for furlough, we have shared your concerns with HMT and HMRC given their oversight of the policy, which they have acknowledged receipt of. Covid economic support schemes, including the Coronavirus Job Retention Scheme, are being examined in Module 9 of the Inquiry, and we await the Inquiry’s recommendations on this issue;”

    Source location

    Response from Cabinet Office
    Page 1 · response
    Published 12 February 2024

    Open published response
  4. Cornwall and Isles of Scilly

    AI-generated summary

    Anthony John WILLIAMSON · 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

    Anthony John Williamson, an experienced kayaker, departed from Trebarwith Strand in a group and was later recovered from the sea after coming out of his kayak in heavy swells at Cambeath Point. He could not be resuscitated, and a final post-mortem cause of death was awaited. Concerns were raised about the adequacy of coastguard cover during the Coronavirus pandemic and whether reduced lifeguard services were being mitigated by additional emergency-service resources.

    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 mitigate shortfalls in lifeguard service with additional emergency service resource

    Wider context from the report

    “It is not clear to me whether there were lifeguards on duty at Trebarwith Strand or elsewhere in north Cornwall at the time of this incident. My further, current cause for concern is that, where there may be a reduced lifeguard service, how any shortfall may be mitigated by additional coastguard or other emergency service resource. Is there a published plan giving notice to the public on how the situation is being managed? ”

    Source location

    Anthony John WILLIAMSON · 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

    Deploy additional Coastguard vehicle patrols to high-risk coastal areas for summer surveillance and rapid search-and-rescue response.

    Verbatim wording from the response

    “To help provide extra surveillance as a Category 1 responder throughout the busy summer season, we have been deploying more HM Coastguard vehicle patrols to high risk areas to keep a look out for any incidents at the coast enabling a swift response to search and rescue if required.”

    Source location

    2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 2 · response
    Published 19 October 2020

    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

    Work closely with Surf Life Saving GB on beach safety services and additional coastal surveillance.

    Verbatim wording from the response

    “HM Coastguard have been working closely since the start of the pandemic with Surf Life Saving GB (SLSGB) who run a programme of Beach Safety services that range from the full lifeguarding provision to providing the public with advice about how to keep safe, by raising awareness of the risks. The SLSGB volunteers are providing a service in some areas in the evenings after RNLI/other lifeguards have left for the day as an”

    Source location

    2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 19 October 2020

    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

    Roll out RNLI lifeguarding cover to 177 beaches during the 2020 season, including 47 beaches in Cornwall.

    Verbatim wording from the response

    “At a Gold meeting on 27 May 2020, it was proposed to look at extending the service beyond 70 beaches. This proposal was subsequently approved by Trustees on the basis that the initial 70 beach model was now proven. Plans were put in place to rollout to an additional 100 beaches by early July, providing cover on c. 170 beaches for the peak season. Work was then undertaken to identify the additional beaches and ensure they could be lifeguarded safely. The rollout of those beaches took place in the period June to August alongside the ongoing rollout to the initial 70 beaches.”

    Source location

    2020-0153-Response-from-the-RNLI.pdf
    Page 6 · response
    Published 19 October 2020

    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

    Provide roving and observational patrols, casualty care, and community access to RNLI rescue equipment at unguarded beaches.

    Verbatim wording from the response

    “The RNLI undertook a significant number of preventive measures including:”

    Source location

    2020-0153-Response-from-the-RNLI.pdf
    Page 7 · response
    Published 19 October 2020

    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 RNLI is responsible for addressing concerns about its risk-based lifeguard deployment during the pandemic.

    Verbatim wording from the response

    “I am aware that because of the pandemic a risk-based approach has been taken by the RNLI to the deployment of lifeguards. However, the RNLI who provide most lifeguard services in the UK will be able to address this point in more detail. The RNLI maintained communication and shared plans throughout this transition period with HMCG regarding the provision of a lifeguard service and their arrangements with Local Authorities.”

    Source location

    2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 19 October 2020

    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

    There is no legal duty to provide lifeguarding, and service provision requires landowner or occupier request or consent.

    Verbatim wording from the response

    “The report is clear that although the RNLI chooses to provide a lifeguarding service, it has no legal duty to do so. Importantly, it cannot provide any service unless the landowner/occupier requests or consents to it. It is entirely a matter for the landowner/occupier whether they ask and contract with the RNLI to provide a lifeguarding service, should they determine to provide a service as a risk control measure.”

    Source location

    2020-0153-Response-from-the-RNLI.pdf
    Page 2 · response
    Published 19 October 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for the public’s use of beaches and related safety decisions rests with the landowner or occupier.

    Verbatim wording from the response

    “In April 2020, the RNLI started work on what steps could be taken to try and mitigate the absence of lifeguards on beaches. However, as set out above, any legal responsibility for the public’s use of beaches is a matter for the landowner/occupier.”

    Source location

    2020-0153-Response-from-the-RNLI.pdf
    Page 7 · response
    Published 19 October 2020

    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

    An immediate full lifeguarding service could not be delivered because achievable cover depended on advance notice of relaxed public restrictions.

    Verbatim wording from the response

    “At the same time as planning the service within the constrictions set out above, the Chief Executive wrote to the Prime Minister and the Department of Transport explaining that it would be impossible to deliver an immediate full service: the level of lifeguarding service which it”

    Source location

    2020-0153-Response-from-the-RNLI.pdf
    Page 5 · response
    Published 19 October 2020

    Open published response
  5. Cornwall and Isles of Scilly

    AI-generated summary

    Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Louisa Davey died after a pleasure craft capsized off the north Cornish coast, trapping her underneath, and Michael Pender died after being rescued from the sea off Treyarnon Bay, apparently having been caught in a rip current. The principal concern was that there was no lifeguard cover on any Cornish beach that day, with uncertainty about when professional lifeguard services would resume and concern about further loss of life.

    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

    Unavailability of professional lifeguard cover on Cornwall beaches

    Wider context from the report

    “On the day of these incidents, there was no lifeguard cover on any Cornish beach. How this state of affairs arose will be a matter for the future. My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing. I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity. Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life. ”

    Source location

    Gillian Louisa DAVEY and Michael PENDER · 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

    Revise and expand summer RNLI lifeguard coverage by working with landowners and councils to confirm additional beach cover.

    Verbatim wording from the response

    “Our original plan was to have lifeguard patrols on 70 beaches this summer. It was a conservative plan and made and announced when many things were still unknown. We now have a better idea of the journey out of lockdown for all parts of the UK, understand the new regulations with which we must comply as an employer and service provider and, most importantly, feel we can properly manage the risks associated with coronavirus. We were on 18 beaches last weekend, 8 of which are in Cornwall, and we are revising our original plans and exploring which additional beaches we can lifeguard this summer. To this end, we are working hard with 55 landowners and local councils to ensure as many beaches as possible will have RNLI lifeguard cover.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 2 · response
    Published 30 July 2020

    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 deaths cannot yet be attributed to the absence of lifeguards because the inquest must determine causation.

    Verbatim wording from the response

    “As you set out in paragraph 5 of your report, your request is based upon the fact you believe that, unless lifeguarding services are back on beaches, there will inevitably be a further loss of life. This pre-supposes that both deaths were caused by a lack of lifeguards, which of course will require an inquest to determine.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Landowners, rather than the RNLI, are responsible for assessing public beach-use risks and providing or arranging lifeguarding.

    Verbatim wording from the response

    “I appreciate your concerns about the prevention of future deaths. Further, I also appreciate that in accordance with Chief Coroner’s Guidance No. 5, you may issue a Regulation 28 Report before an inquest is concluded. However, in this instance I believe the Regulation 28 Report is premature and has been made without the benefit of all the relevant information; this includes the fact it is the landowner, not the RNLI, who has the responsibility to carry out risk assessments covering the public use of beaches, and then to mitigate the risks they identify by, amongst other things, providing a lifeguarding service.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Beach safety is outside the agency’s statutory or specific responsibilities.

    Verbatim wording from the response

    “The Department for Transport and the Maritime & Coastguard Agency have an interest in maritime safety generally because we want to see fewer accidents and less demand on the emergency services that we coordinate to respond to search and rescue missions. That is why we promote initiatives such as the annual Maritime Safety Week alongside partner organisations and we use our social media and other channels to communicate safety campaigns and messages. We do not have any statutory or specific responsibilities for beach safety.”

    Source location

    2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Lifeguarding services cannot provide an absolute guarantee of beach safety because they are limited in coverage, hours and seasonality.

    Verbatim wording from the response

    “Fundamentally and ultimately, however, people have a personal responsibility for their own safety in and around water and on beaches. Landowners, local authorities and others can provide safety information including signage and public rescue equipment, but it is individuals taking responsibility for their own safety and actions that will keep most people safe. Even where beach owners carry out a risk assessment and conclude that they can support safety by providing a lifeguarding service, whether from the RNLI or another provider, those services will not operate 24 hours a day and always cover just a limited area of each beach. Deployment will also be seasonal to take account of the times of year when the risk is judged to be at its highest. The provision of a lifeguarding service is not, and can never be, an absolute guarantee of safety.”

    Source location

    2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 3 · response
    Published 30 July 2020

    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

    Beach safety and lifeguarding provision fall outside the respondent’s remit, which is limited to coordinating coastal and sea search-and-rescue responses.

    Verbatim wording from the response

    “In your report, under Section 6, you say that the Department for Transport, the RNLI and the Maritime and Coastguard Agency (MCA) have the powers to take action in respect to providing a lifeguard service on beaches in Cornwall, to help prevent the future loss of life. The MCA, which includes Her Majesty’s Coastguard, is an executive Agency of the Department for Transport. I am therefore replying on my own behalf, and also on behalf of the Secretary of State for Transport, the Right Honourable Grant Shapps MP. The MCA has a responsibility to respond to calls for assistance as the emergency responder with the remit for search and rescue at the coast and at sea. Our role is to coordinate the emergency response drawing from the matrix of search and rescue resources that are available and appropriate. However, we have no remit for beach safety or the provision of lifeguarding.”

    Source location

    2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    Open published response
  6. Cornwall and Isles of Scilly

    AI-generated summary

    Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Davey, aged 17, was trapped under a capsized pleasure craft near Padstow and could not be resuscitated. On the same day, Michael Pender, aged 63, was rescued after apparently being caught in a rip current while swimming off Treyarnon Bay, but could not be resuscitated. The principal concern was that no Cornish beach had lifeguard cover that day and that beaches remained unguarded, with a fear of further loss of life until professional lifeguard services returned.

    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 professional lifeguard cover on Cornwall’s beaches

    Wider context from the report

    “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach. How this state of affairs arose will be a matter for the future. My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing. I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity. Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life. ”

    Source location

    Gillian Louisa DAVEY and Michael PENDER · 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

    Revise and expand summer RNLI lifeguard coverage by working with landowners and councils to confirm additional beach cover.

    Verbatim wording from the response

    “Our original plan was to have lifeguard patrols on 70 beaches this summer. It was a conservative plan and made and announced when many things were still unknown. We now have a better idea of the journey out of lockdown for all parts of the UK, understand the new regulations with which we must comply as an employer and service provider and, most importantly, feel we can properly manage the risks associated with coronavirus. We were on 18 beaches last weekend, 8 of which are in Cornwall, and we are revising our original plans and exploring which additional beaches we can lifeguard this summer. To this end, we are working hard with 55 landowners and local councils to ensure as many beaches as possible will have RNLI lifeguard cover.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 2 · response
    Published 30 July 2020

    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 deaths cannot yet be attributed to the absence of lifeguards because the inquest must determine causation.

    Verbatim wording from the response

    “As you set out in paragraph 5 of your report, your request is based upon the fact you believe that, unless lifeguarding services are back on beaches, there will inevitably be a further loss of life. This pre-supposes that both deaths were caused by a lack of lifeguards, which of course will require an inquest to determine.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Landowners, rather than the RNLI, are responsible for assessing public beach-use risks and providing or arranging lifeguarding.

    Verbatim wording from the response

    “I appreciate your concerns about the prevention of future deaths. Further, I also appreciate that in accordance with Chief Coroner’s Guidance No. 5, you may issue a Regulation 28 Report before an inquest is concluded. However, in this instance I believe the Regulation 28 Report is premature and has been made without the benefit of all the relevant information; this includes the fact it is the landowner, not the RNLI, who has the responsibility to carry out risk assessments covering the public use of beaches, and then to mitigate the risks they identify by, amongst other things, providing a lifeguarding service.”

    Source location

    2020-0121-Response-from-RNLI_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Beach safety is outside the agency’s statutory or specific responsibilities.

    Verbatim wording from the response

    “The Department for Transport and the Maritime & Coastguard Agency have an interest in maritime safety generally because we want to see fewer accidents and less demand on the emergency services that we coordinate to respond to search and rescue missions. That is why we promote initiatives such as the annual Maritime Safety Week alongside partner organisations and we use our social media and other channels to communicate safety campaigns and messages. We do not have any statutory or specific responsibilities for beach safety.”

    Source location

    2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    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

    Lifeguarding services cannot provide an absolute guarantee of beach safety because they are limited in coverage, hours and seasonality.

    Verbatim wording from the response

    “Fundamentally and ultimately, however, people have a personal responsibility for their own safety in and around water and on beaches. Landowners, local authorities and others can provide safety information including signage and public rescue equipment, but it is individuals taking responsibility for their own safety and actions that will keep most people safe. Even where beach owners carry out a risk assessment and conclude that they can support safety by providing a lifeguarding service, whether from the RNLI or another provider, those services will not operate 24 hours a day and always cover just a limited area of each beach. Deployment will also be seasonal to take account of the times of year when the risk is judged to be at its highest. The provision of a lifeguarding service is not, and can never be, an absolute guarantee of safety.”

    Source location

    2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 3 · response
    Published 30 July 2020

    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

    Beach safety and lifeguarding provision fall outside the respondent’s remit, which is limited to coordinating coastal and sea search-and-rescue responses.

    Verbatim wording from the response

    “In your report, under Section 6, you say that the Department for Transport, the RNLI and the Maritime and Coastguard Agency (MCA) have the powers to take action in respect to providing a lifeguard service on beaches in Cornwall, to help prevent the future loss of life. The MCA, which includes Her Majesty’s Coastguard, is an executive Agency of the Department for Transport. I am therefore replying on my own behalf, and also on behalf of the Secretary of State for Transport, the Right Honourable Grant Shapps MP. The MCA has a responsibility to respond to calls for assistance as the emergency responder with the remit for search and rescue at the coast and at sea. Our role is to coordinate the emergency response drawing from the matrix of search and rescue resources that are available and appropriate. However, we have no remit for beach safety or the provision of lifeguarding.”

    Source location

    2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
    Page 1 · response
    Published 30 July 2020

    Open published response
  7. Inner North London

    AI-generated summary

    Anthony Cleon GRANT · 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

    Anthony Cleon Grant suffered a cardiac event while swimming in a public pool, drifted to the bottom, and died on poolside after lifeguards attempted resuscitation. The principal concern was that he remained submerged for five minutes and 41 seconds before being noticed, raising issues about lifeguard positioning, the number of lifeguards, and the possible use of motion early warning systems and training footage.

    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 change lifeguard positions at planned intervals

    Wider context from the report

    “Mr Grant drifted under the water and remained submerged for five minutes and 41 seconds before a member of the public noticed him and alerted a lifeguard. The lifeguard had been on duty poolside throughout. Quite apart from the actions of an individual lifeguard, there are many ways that pool safety could have been approached differently that day. The lifeguards could have changed position after half an hour or an hour as had been intended. There could have been more than one lifeguard on poolside. The lifeguards could have been supported by a motion early warning system. These are all matters for the industry to explore. ”

    Source location

    Anthony Cleon GRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. West Sussex

    AI-generated summary

    Alfie Wayne Eddie Gray · 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

    Alfie Wayne Eddie Gray, aged 7, drowned in a hotel resort pool in Sharm El Sheikh, Egypt, on 7 July 2015 after he went missing while playing in the pool. Concerns were raised that lifeguard provision was inadequate, lifeguards lacked medical training, communication was difficult, and lifeguards were off duty during lunchtime without this being communicated to the family.

    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 lifeguard communication with holiday makers during emergencies

    Wider context from the report

    “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate. The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed. ”

    Source location

    Alfie Wayne Eddie Gray · 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

    Inadequate lifeguard staffing levels

    Wider context from the report

    “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate. The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed. ”

    Source location

    Alfie Wayne Eddie Gray · 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 to maintain continuous lifeguard coverage

    Wider context from the report

    “(2) The lifeguards went off duty for an hour over lunchtime. This information was not communicated to the family either by the hotel or the travel company. ”

    Source location

    Alfie Wayne Eddie Gray · 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

    Lack of medical training for lifeguards

    Wider context from the report

    “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate. The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed. ”

    Source location

    Alfie Wayne Eddie Gray · 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

    Continue promoting member guidance that accommodation staff receive lifesaving, CPR and first-aid training.

    Verbatim wording from the response

    “The Technical Guide section on Pool Safety addresses emergency procedures from management responsibility to appropriate staff training. The Management Responsibility section addresses the need to train staff in lifesaving techniques, CPR and first aid. We believe that this reflects current best practice and we continue to promote this approach for Members to their suppliers.”

    Source location

    2016-0262-Response-by-ABTA
    Page 2 · response
    Published 25 July 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Technical Guide’s emergency procedures and staff training requirements reflect current best practice for lifesaving techniques, CPR and first aid.

    Verbatim wording from the response

    “The Technical Guide section on Pool Safety addresses emergency procedures from management responsibility to appropriate staff training. The Management Responsibility section addresses the need to train staff in lifesaving techniques, CPR and first aid. We believe that this reflects current best practice and we continue to promote this approach for Members to their suppliers.”

    Source location

    2016-0262-Response-by-ABTA
    Page 2 · response
    Published 25 July 2016

    Open published response
  9. Manchester West

    AI-generated summary

    Loui Aspinall · 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

    Loui Aspinall died after walking into a swimming pool at a hotel resort in Tunisia and becoming submerged. The concerns included the apparent absence of obvious resuscitation and rescue equipment, uncertainty about lifeguard provision and first-aid training, and gaps in tour-operator best-practice guidance on pool safety and emergency procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of best-practice requirements for first-aid-trained swimming-pool lifeguards

    Wider context from the report

    “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool. ”

    Source location

    Loui Aspinall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Essex

    AI-generated summary

    Josephine Foday and Komba Kpakiwa · 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

    Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

    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 lifeguards or effective drowning-risk controls

    Wider context from the report

    “4) There were no lifeguards provided and the duty holders of the pool did not ensure that there were in place effective controls in place to reduce the risk of drowning ”

    Source location

    Josephine Foday and Komba Kpakiwa · 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 swimming pool is closed, so no one else will be exposed to a similar risk at that facility.

    Verbatim wording from the response

    “We understand that the swimming pool concerned is now closed and so no-one else will be put at similar risk in this facility.”

    Source location

    2014-0301-Response-by-IOSH
    Page 1 · response
    Published 23 May 2014

    Open published response
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Data last updated 7 September 2026