Recurring concern

Inadequate controls preventing falls from water-adjacent public routes

First to latest report 15 Nov 2013 — 22 Feb 2023

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
8

What this concern includes

Includes hazardous public paths, bridleways, harbour walls, piers and comparable routes where an adjacent drop or water creates a material fall risk and dedicated controls such as barriers, edge protection, access restrictions or hazard warnings are absent, inadequate or unreliable.

What is not included
  • Excludes general open-water drowning risks where no water-adjacent public route or edge-fall hazard is identified.
  • Excludes ordinary path-surface, lighting, wayfinding and maintenance deficiencies that do not create a risk of falling from the route into water.
  • Excludes bridges, balconies, multi-storey car parks and other elevated structures where the supported concern is not a public route beside water.
  • Excludes falls or collisions without an asserted continuing deficiency in controls for a water-adjacent route fall hazard.

Reports and published responses 3 reports

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

  1. Cornwall and Isles of Scilly

    AI-generated summary

    James Francis PARSONS · 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

    James Francis PARSONS died by drowning at Porthleven Harbour on 23 April 2022 after falling from the harbour wall into the water. The report identified safety concerns including sheer drops without railings, trip hazards, poor lighting, the absence of access ladders or refuge areas, and the pier being open to the public during the festival.

    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 railing protection alongside harbour and pier sheer drops

    Wider context from the report

    “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

    Source location

    James Francis PARSONS · Prevention of Future Deaths report
    Page 3 · 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

    Statutory health and safety enforcement for dock premises falls outside the council’s powers under the Health and Safety at Work etc. Act 1974.

    Verbatim wording from the response

    “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 28 February 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 Health and Safety Executive is responsible for statutory enforcement concerning safety at the harbour’s dock premises.

    Verbatim wording from the response

    “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 28 February 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

    Existing railings, signage and lifebuoy aids are considered sufficient to address harbour safety risks.

    Verbatim wording from the response

    “Over the years, the Harbour & Dock Company has given the utmost priority to safety aspects of the Harbour and continues to do so each year. We are satisfied with the measures we have in place which include railings, signage and lifebuoy aids. Being a popular holiday destination, Porthleven attracts thousands of visitors each year without incident which clearly demonstrates the Harbour is a safe environment.”

    Source location

    Response from Porthleven Harbour Dock Company
    Page 3 · response
    Published 28 February 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

    HSE has no regulatory powers over harbour areas without work activity or risks increased by festivals and other public events.

    Verbatim wording from the response

    “Porthleven Harbour is mainly concerned with recreational activities, including the mooring of privately owned pleasure boats. The Health and Safety at Work etc. Act 1974 only applies to Porthleven Harbour at locations where a work activity is taking place. That is paid work or where there is some form of remuneration, there is an employer/employee or self-employed person. Where the Act does not apply, HSE has no vires or regulatory powers.”

    Source location

    Response from Health and Safety Executive
    Page 1 · response
    Published 28 February 2023

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Sopeluwa Babatunde Peters · 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

    Sopeluwa Babatunde Peters died by drowning in the River Wear on 30 October 2013, after likely falling into the river while descending steep steps in Drury Lane, Durham City, while under the influence of alcohol. Concerns included poor illumination, the absence of a handrail, the steepness of the steps, and a low riverside wall that provided limited safety protection.

    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

    Low riverside wall providing inadequate safety barrier

    Wider context from the report

    “(1) The steps are steep, poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier. ”

    Source location

    Sopeluwa Babatunde Peters · 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

    Install a timber barrier beside the wall opposite Drury Lane’s exit to reduce the risk of falls into the river.

    Verbatim wording from the response

    “I can confirm that whilst no action is being proposed in respect of the above mentioned matters, the Council will be installing a timber barrier in the riverside footpath, adjacent to the wall opposite the exit from Drury Lane. The installation of a barrier should reduce any potential risk of someone falling or running down the steps and going over the wall into the river at this location. This barrier will be placed within the footpath itself, as the path is within the control of the County Council. It is anticipated that this barrier will be installed within the next two weeks.”

    Source location

    2014-0206-Response-by-Durham-County-Council
    Page 2 · response
    Published 8 May 2014

    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

    Undertake a riverbank risk assessment with police representatives to identify locations associated with evening and night-time activity.

    Verbatim wording from the response

    “The County Council will also be undertaking a risk assessment along sections of the river bank. This assessment will include representatives from the police who will identify locations, from their local knowledge of where there is a volume of evening and night time activity. If further risks are identified these will be assessed and action will be taken by the County Council to minimise such risks as is considered appropriate.”

    Source location

    2014-0206-Response-by-Durham-County-Council
    Page 2 · response
    Published 8 May 2014

    Open published response

  3. Derby and Derbyshire

    AI-generated summary

    David Allan Cox · 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 Allan Cox died after his vehicle left a narrow, icy bridleway at a sharp blind bend, overturned and entered the river. The principal concern was that the absence of barriers, together with the narrow track and further blind bends, created an ongoing risk of vehicles leaving the bridleway and entering the river.

    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

    Absence of a barrier between the bridleway and the river

    Wider context from the report

    “The track at the point of the bend where the vehicles left the track on 24th January 2013 being extremely narrow and acute, leaving no margin for error and creating a risk of other vehicles leaving the track and sliding down the river bank into the river below due to the absence of any barrier. There is no barrier or wall along the length of the bridleway between the track and the river and I had confirmed in evidence that there are in total three blind bends along the length of the bridleway. The presence of two further blind bends along the same track also causes me concern. The concern is that circumstances creating a risk of further deaths will occur or will continue to exist in the future relating to the risk of vehicles leaving the narrow bridleway at the blind bends and rolling into the river due to the track being extremely narrow and the absence of any barrier between the bridleway and the river below. ”

    Source location

    David Allan Cox · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Notify relevant organisations and residents about identified safety issues and seek their input and required consents for proposed works.

    Verbatim wording from the response

    “e. The Authority made initial written contact with key organisations, including the Partners, on 3 December 2013 to inform them of the issues identified during the inquest, to put them on notice of the impending PFD Report and your emphasis of the need for their input into the consideration and approval of any action taken by the Authority. The key organisations were notified before receipt of the PFD Report and the expert reports (outlined below) to facilitate the implementation of any identified actions as soon as possible. The organisations contacted in early December are as follows:”

    Source location

    2013-0355-Response
    Page 2 · response
    Published 15 November 2013

    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

    Commission and complete a survey assessing river-bank stability, hydrological issues, track widening, and potential safety engineering measures.

    Verbatim wording from the response

    “The River Wye Bank Stabilisation Works – Site Assessment Report (the “Survey Report”) was funded and commissioned by the Authority prior to the inquest. The report, which addresses bank stability and wider hydrological issues along the entire length of the track, was prepared by Silkstone Environmental Ltd and SM Foster Associates Ltd further to their respective bank stability and hydrological assessments. A copy is enclosed for your information. Although Silkstone carried out their initial on-site”

    Source location

    2013-0355-Response
    Page 2 · response
    Published 15 November 2013

    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

    Develop a detailed works specification by appointing replacement specialist engineering expertise and coordinating required safety, gabion, and design input.

    Verbatim wording from the response

    “h. Specification for Works”

    Source location

    2013-0355-Response
    Page 3 · response
    Published 15 November 2013

    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

    Commission technical tender documents and invite at least three appropriately qualified contractors to bid for the proposed works.

    Verbatim wording from the response

    “j. Tendering Process”

    Source location

    2013-0355-Response
    Page 4 · response
    Published 15 November 2013

    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 pursuing required consents from partners during specification development and tendering.

    Verbatim wording from the response

    “g. The Survey Report was forwarded to the residents and the organisations listed above within paragraph ‘e’ on 16 and 17 January for comment by no later 14 February 2014. You will recall from the inquest that the Authority consulted with DCC and Natural England, and required consent from the Environment Agency and Network Rail, in respect of previous minor bank repair works carried out in April 2013. This previous process took 2 months and did not entail the extent of preparatory work or technical input required in respect of the works proposed within the Survey Report. In light of the much larger scale of the proposed works the Authority has requested consent from all of the Partners.”

    Source location

    2013-0355-Response
    Page 3 · response
    Published 15 November 2013

    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

    Investigate external funding streams and liaise with Derbyshire County Council about incorporating the proposed safety works into its programme.

    Verbatim wording from the response

    “l. Funding”

    Source location

    2013-0355-Response
    Page 5 · response
    Published 15 November 2013

    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