Recurring concern

Unreliable pre-activity safety liaison arrangements

First to latest report 20 Jul 2015 — 1 Oct 2015

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 2

What this concern includes

Includes failures to identify relevant external safety partners, agree their roles, exchange participant or activity-risk information, establish emergency-support arrangements and confirm those arrangements before an organised activity begins.

What is not included

Excludes generic communication or coordination failures without an explicit pre-activity safety-liaison context.
Excludes emergency response failures occurring after an activity has begun when pre-activity liaison was adequately established.
Excludes routine activity planning, commercial coordination or general stakeholder consultation where no participant-safety or emergency-support purpose is identified.
Excludes failures within a named clinical, rescue or transport service after the pre-activity arrangements have been established.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Defence1

Recipient name withheld1

Sport Camp Tirol1

Reports and published responses 2 reports

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

1 Oct2015
Stoke-on-Trent and North Staffordshire
Concerns raised2
1. Lack of pre-activity liaison between rafting provider and Army
2. Lack of obligation for rafting operators to ascertain significant TIWAG discharges
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sport Camp Tirol
Stated actions 1
1. Sport Camp Tirol
  Prohibit rafting downstream of the storage tanks on days when a discharge is planned.
Respondent positions 2
1. Sport Camp Tirol
  The hydro plant was responsible for conducting discharges safely and informing affected river users.
  Redirects responsibility
1. Sport Camp Tirol
  Advance discharge notifications now provide sufficient time to cancel or re-plan rafting trips.
  Existing arrangements considered sufficient
AI-generated summary

John Lomas · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of pre-activity liaison between rafting provider and Army
Wider context from the report
“1. There had been no liaison between Sport Camp Tirol and the Army prior to the white water rafting Trip that took place on the 21st June 2012. No generic risk assessment had been provided to or requested by Sports Camp Tirol as a result there was a lack of understanding as to the suitability of soldiers to undertake the trip. ”
Source location
John Lomas · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 obligation for rafting operators to ascertain significant TIWAG discharges
Wider context from the report
“9. There was no obligation to liaise with TIWAG Water Company to ascertain when a significant stowage discharge would take place and TIWAG had no obligation to notify rafting companies downstream who might be affected by the discharge. (The last discharge had been two and half years prior to this incident.) ”
Source location
John Lomas · 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
Prohibit rafting downstream of the storage tanks on days when a discharge is planned.

Verbatim wording from the response
“Since the incident I have become aware of the possibility of such discharges and steps have been taken so that the rafting companies are now informed FROM THE HYDRO PLANT COMPANY well in advance so that we can plan around such an event - most importantly prevent tours from taking place during a discharge. We have internally made the decision in the regard of safety to do no rafting trips downstream of these storage tanks on the same day they are planned to be released.”

Source location
Response-by-Sport-Camp-Tirol
Page 2 · response
Published 1 October 2015
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 hydro plant was responsible for conducting discharges safely and informing affected river users.

Verbatim wording from the response
“with all rafts and guests and had absolutely NO INFLUENCE on the incident whatsoever. I would like to make an analogy to further explain this situation. Should a bus company that has a permit to take guests down a given road have to call before every trip to ANY and ALL persons who may plan to roll a large amount of timer down the road without warning, without informing the road users and without closing the road to traffic? How are we as a company supposed to have knowledge of ANY business upstream that is about to dump large quantities of potentially dangerous material into the river without notice? It is clearly the responsibility of the Hydro plant to ensure that their discharge is conducted in a safe manor and that they inform all potentially affected individuals of their actions.”

Source location
Response-by-Sport-Camp-Tirol
Page 3 · response
Published 1 October 2015
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
Advance discharge notifications now provide sufficient time to cancel or re-plan rafting trips.

Verbatim wording from the response
“Since the incident I have become aware of the possibility of such discharges and steps have been taken so that the rafting companies are now informed FROM THE HYDRO PLANT COMPANY well in advance so that we can plan around such an event - most importantly prevent tours from taking place during a discharge. We have internally made the decision in the regard of safety to do no rafting trips downstream of these storage tanks on the same day they are planned to be released.”

Source location
Response-by-Sport-Camp-Tirol
Page 2 · response
Published 1 October 2015
Open published response
20 Jul2015
Birmingham and Solihull
Concerns raised1
1. Lack of prior liaison with NHS and mountain rescue for exercise casualties
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Ministry of Defence
Stated actions 1
1. Ministry of Defence
  Liaise with local police, Mountain Rescue, search and rescue, and hospitals before exercises, and rehearse responses to medical emergencies.
AI-generated summary

Craig Roberts 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

Craig Roberts, James Dunsby and Edward Maher were reserve soldiers taking part in a specialist-unit selection test march in the Brecon Beacons in July 2013. The report identifies concerns about heat-illness guidance, training and risk assessment, communication of weather information, medical planning, emergency response, tracking of slow or static candidates, and the failure to implement lessons from previous incidents.

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 prior liaison with NHS and mountain rescue for exercise casualties
Wider context from the report
“(13) There was no prior liaison with the NHS and Mountain rescue before this exercise about what their involvement might be in the case of any injuries or illness. ”
Source location
Craig Roberts 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
Liaise with local police, Mountain Rescue, search and rescue, and hospitals before exercises, and rehearse responses to medical emergencies.

Verbatim wording from the response
“Local Commanders now liaise with local Police and Mountain Rescue prior to the start of every exercise. In addition, communications are established with the closest Search and Rescue location to confirm the communications plan and Medical Staff are required to liaise with local hospitals. The Medical Officers that rehearse and virtual exercises be undertaken to consider the response, including likely timelines, to medical emergencies.”

Source location
2015-0228-Response-by-MOD
Page 7 · response
Published 20 July 2015
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Lack of pre-activity liaison between rafting provider and Army

Lack of obligation for rafting operators to ascertain significant TIWAG discharges

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of prior liaison with NHS and mountain rescue for exercise casualties

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Stated actions 1

Respondent positions 2

Stated actions 1