Recurring concern

Inadequate water rescue provision for recreational water activities

First to latest report 1 Oct 2015 — 27 Feb 2023

Reports that mention this concern
6
Times this concern has been raised
7
Stated actions linked to this concern
5

What this concern includes

Includes failures of dedicated water-rescue provision for recreational water activities, including safety kayaks, rescue equipment, rescue access arrangements and related operational controls intended to reach or recover people in the water.

What is not included
  • Excludes general water hazards, water-safety warnings or risk assessments where no deficiency in rescue provision is identified.
  • Excludes generic staff training or staffing deficiencies unless they directly impair dedicated water-rescue provision.
  • Excludes water-rescue arrangements for emergency services or occupational operations unless the concern specifically concerns recreational water activities.
  • Excludes unrelated personal flotation, boating or watercraft controls where rescue provision is not the shared unsafe condition.

Reports and published responses 6 reports

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

  1. Bedfordshire and Luton

    AI-generated summary

    Kyron Marcus HIBBERT · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of promptly accessible lifesaving equipment at the lakeside

    Wider context from the report

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

    Source location

    Kyron Marcus HIBBERT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Install additional unlocked throw lines and accompanying safety signage near the high-water mark at Locations 5 and 7 and other previously affected locations.

    Verbatim wording from the response

    “Whilst it is not accepted the secure throw lines were “very far away” from the water , in order to deal with HM Senior Coroner’s concern on this issue the Trust will install additional unlocked lines closer to the high water mark of the lake at locations 5 and 7 , and at the other points around the lake and closer to the edge of the lake in locations where there have been previous incidents of swimming.”

    Source location

    Response from DAC Beachcroft
    Page 3 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

    Response from DAC Beachcroft
    Page 1 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust disputes that locked throwlines were inaccessible, stating that children could obtain the access code through emergency services.

    Verbatim wording from the response

    “The Head Ranger’s evidence at inquest was that locked throw lines in a number of locations had replaced unlocked throw lines, not life rings. There were therefore a combination of locked and unlocked throw lines around the lake at the time of this incident. The design of the locked throw lines was arrived at following consultation with Bedfordshire Fire and Rescue and reflects that used by the local authority in the Bedford area. The locked line was accessible to the children if one of them had followed the instructions on the signage to obtain the access code from the emergency operator. The written evidence on the issue was that one of the children had no battery power in her phone. It is highly likely others had mobile phones that were working.”

    Source location

    Response from DAC Beachcroft
    Page 3 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust considers that changing lifesaving-equipment positioning would not have altered the fatal outcome in this case.

    Verbatim wording from the response

    “All at the Trust was devastated by Kyron’s death and it will go above and beyond its legal duty to try and avoid a similar incident. That said the Trust believes the evidence in this case sadly confirmed the positioning or availability of life saving equipment would not have altered the fatal outcome of this case.”

    Source location

    Response from DAC Beachcroft
    Page 4 · response
    Published 10 March 2023

    Open published response

  2. Inner West London

    AI-generated summary

    Henry Huw Duncan Campbell · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of on-site deep-water rescue equipment and staff

    Wider context from the report

    “1. That the Peligoni Club should consider instructing an appropriate expert to assess whether the club should have on site equipment (SCUBA) and staff that would allow them to effect deep-water rescue. ”

    Source location

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

    Open source report

  3. Staffordshire South

    AI-generated summary

    Evha Jannath · 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

    Evha Jannath, aged 11, fell into deep water during a water rapids ride at Drayton Manor Theme Park after being projected from a boat and later falling from a wet conveyor belt. She was located and recovered after 18 minutes. The principal concerns included inadequate CCTV monitoring, lack of safety warnings, worn or incomplete signage, insufficient water-rescue training and equipment, and unclear 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

    Unavailability of water rescue equipment

    Wider context from the report

    “(4) Staff had not been trained in water rescue and there was no water rescue equipment available. ”

    Source location

    Evha Jannath · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. 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

    Failure to plan how rescue would be conducted during open-water activities

    Wider context from the report

    “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”

    Source location

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

    Open source report

  5. Blackpool and the Fylde

    AI-generated summary

    Jane Bell · 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

    Jane Bell drowned in a hotel swimming pool after going underwater in the deep end and later died in hospital on 14 August 2014. The principal concern was that the hotel’s arrangements for pool supervision, including CCTV monitoring and infrequent poolside patrols, remained insufficient to prevent future deaths, particularly where staff could be distracted and a child could remain underwater for a fatal period.

    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 maintain immediate child-rescue availability during pool monitoring

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 5 · 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

    Insufficient poolside equipment for rescuing a submerged child

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 6 · 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

    Provide constant poolside supervision through trained patrol and reception CCTV monitoring whenever the pool is open.

    Verbatim wording from the response

    “Since the inquest the Hotel has had constant poolside supervision in place at all times when the pool is open regardless of whether it is in use. This involves one member of staff (with poolside responder training) constantly patrolling at the poolside and another member of staff (also poolside responder trained) continually monitoring the CCTV footage from the reception desk.”

    Source location

    Jane-Bell-Response
    Page 1 · response
    Published 22 March 2016

    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

    Train leisure and reception staff in poolside patrols, bather head counts, behaviour monitoring and poolside response.

    Verbatim wording from the response

    “At the inquest I, Samantha Lewis on behalf of the Dalmeny Hotel confirmed that all members of the leisure staff which includes those based primarily on reception, have poolside responder training. This would enable a member of staff to appropriately deal with an incident in the pool, including diving to the bottom of the pool at its depth of 2.44m to effect a rescue.”

    Source location

    Jane-Bell-Response
    Page 1 · response
    Published 22 March 2016

    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

    Continue refresher training for all staff in poolside response.

    Verbatim wording from the response

    “All members of staff will continue to receive refresher training on poolside responder.”

    Source location

    Jane-Bell-Response
    Page 2 · response
    Published 22 March 2016

    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

    Carry out documented opening and closing pool-hall safety inspections covering rescue equipment, water clarity, lighting, signage and staff communications.

    Verbatim wording from the response

    “In addition to this there are documented pool hall safety checks and inspections carried out on opening and closing. These inspections consist of checking the water rescue equipment, looking at the water clarity and lighting and signage and also require the communication folder to be read. The communication folder updates members of staff as to any changes or issues with the pool the previous day.”

    Source location

    Jane-Bell-Response
    Page 2 · response
    Published 22 March 2016

    Open published response

  6. 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

    Unavailability of a safety kayak

    Wider context from the report

    “7. There was no safety kayak. ”

    Source location

    John Lomas · 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

    Additional safety kayaks were unnecessary because three rafts provided mutual safety cover, and kayaks are not legally required.

    Verbatim wording from the response

    “7. Safety kayaks are not required on any river under Austria law. We do use safety kayaks in our company in particular when we only have a single raft on a trip or are doing the harder river sections in high water. On the day of the incident we had three rafts each making safety cover for the other two. No request was made by the guides for the addition of a safety kayak. We do use safety kayakers even though we do not have to by law. We also double guide our rafts (2 guides on a single raft) when we only have one raft on a trip at river grades above grade 3 - this is also not required by law but we do it in the interests of safety - not all companies are as safety conscious as we are!”

    Source location

    Response-by-Sport-Camp-Tirol
    Page 7 · response
    Published 1 October 2015

    Open published response

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

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Data last updated 7 September 2026