Recurring concern

Inadequate public water-rescue equipment and arrangements

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First reported 22 Jan 2014•Latest report 26 Feb 2026

Definition

What this concern includes

Includes failures of dedicated public water-rescue equipment and operational arrangements at beaches, rivers and comparable public waterside locations, including equipment location awareness, accessibility, secure placement, serviceability, protection from weather or vandalism, adequacy and responder familiarity with its use.

Not included

Excludes emergency water-rescue procedures and equipment used solely by professional emergency responders where public rescue-equipment availability or use is not the reported condition.
Excludes recreational water-activity rescue provision where the concern is safety coverage for participants rather than publicly available rescue equipment at the waterside.
Excludes general drowning hazards, lifeguard coverage, water-safety education and site warnings where no dedicated water-rescue equipment or locating-and-use arrangement is deficient.

Reports: 5
Individual concerns: 6
Date range: 2014–2026
Stated actions: 8

Reports 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.

Canal & River Trust1

City of York Council1

Eastbourne Pier1

North Yorkshire Fire and Rescue Service1

North Yorkshire Police1

Sussex Police1

The Forest Of Marston Vale Trust1

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.

26 Feb2026
Cheshire
Concerns raised1
1. Lack of means for people to get out of the canal unaided
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Coordinate with the Water Safety Partnership and relevant landowners to identify and discuss potential additional water-safety mitigation measures.
  Stated by Canal & River TrustStated in progress
Respondent positions 1
1. Position
  Direct action on public-realm water safety risks is limited because the surrounding land is not owned or controlled by the respondent.
  Stated by Canal & River TrustUnable to act
AI-generated summary

William Anthony Elvis WEBB · 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

William Webb was reported missing after failing to return home and was later found deceased in the Shropshire Union canal on 24 November 2025. CCTV indicated that he likely accidentally fell into the canal on 23 November and died by drowning after being unable to self-rescue. The report raised concerns about the absence of safety equipment and nearby warning signage, and the difficulty of getting out because of the distance between the water and the ground edge.

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 means for people to get out of the canal unaided
Wider context from the report
“The area in which Mr Webb fell into the canal is close to student accommodation. Whilst this is a generalisation and is by no means all students, students as a group are within the demographic of people who will attend the bars, pubs and nightclubs of Chester and become inebriated to varying degrees. Once under the influence of alcohol, or perhaps another substance, it is then not inconceivable that they then take less care/ are more willing to engage in risky behaviours. The canal is near to their accommodation, which makes it more likely that they will be in that area. Once in the water, there is currently no safety equipment which could assist someone in getting out, whether they are in accidentally or intentionally, and the distance between the water level and the ground edge (the freeboard), is, in my view, such that it would be difficult to get out without assistance. There is also no signage nearby which alerts people to the potential risks. I heard varying evidence as to the depth of the water, with the police describing it as around 5ft, and the Canal and River Trust indicating it was around 1 metre. ”
Source location
William Anthony Elvis WEBB · 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
Coordinate with the Water Safety Partnership and relevant landowners to identify and discuss potential additional water-safety mitigation measures.

Verbatim wording from the response
“• Consequently and to address the specific risks presented by the public realm over which the Trust has no control, I have, on behalf of the Trust, requested the WSP’s support in writing to relevant riparian owners of the land surrounding the Shropshire and Union Canal, inviting them to a meeting to discuss what further steps can be taken collectively, or on an individual basis to provide additional mitigation of water safety risks in this area. Layout of the public realm, signage, lighting and the provision of Personal Rescue Equipment are to be raised, the necessity and benefit of which will be considered alongside issues such as the depth of the water and the height of the freeboard. We will work proactively with the WSP and the relevant landowners to identify where such measures may be implemented/improved and provide advice and assistance where we are able to do so.”

Source location
Response from Canal & River Trust
Page 1 · response
Published 3 March 2026
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
Direct action on public-realm water safety risks is limited because the surrounding land is not owned or controlled by the respondent.

Verbatim wording from the response
“As indicated in the Trust’s initial response (dated 3rd of February 2026) to your questions preceding the Inquest, the land surrounding the Shropshire Union Canal in the vicinity of the University accommodation, and crucially where Mr Webb entered the water, is not owned by the Trust. This presents a number of challenges and limits the actions we are able to take directly. Notwithstanding and following the Inquest and the concerns raised in the Regulation 28 Report (dated 26th February 2026), the Trust has taken the following actions:”

Source location
Response from Canal & River Trust
Page 1 · response
Published 3 March 2026
Open published response
10 Nov2023
East Sussex
Concerns raised2
1. Insufficient length of ropes attached to life-saving rings for reaching the water at low tide
2. Failure to keep life-saving rings visible and easily accessible
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Increase the ropes on all life-saving rings to 50 metres.
  Stated by Eastbourne PierStated completed
AI-generated summary

Graham Ian COOMBE · 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

Graham Ian COOMBE entered the water from the lower level of Eastbourne Pier on 1 May 2022 and was rescued by lifeboat after attempts to reach him were delayed by access and lifesaving-equipment issues. He died at Royal Sussex County Hospital Brighton on 4 May 2022 as a result of drowning. Concerns included a locked access gate, an inaccessible and poorly visible lifesaving ring, a rope that was too short to reach the water at low tide, and the number of lifesaving rings on the pier.

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
Insufficient length of ropes attached to life-saving rings for reaching the water at low tide
Wider context from the report
“3. The rope attached to the life saving ring was too short (although its length was within the prescribed regulatory guidelines) so that the buoyancy aid did not reach the water when thrown. I am concerned that the rope was of an insufficient length for the aid to reach the water at low tide. ”
Source location
Graham Ian COOMBE · 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
Failure to keep life-saving rings visible and easily accessible
Wider context from the report
“2. The life saving ring was neither in an accessible or visible place. It was in a cupboard hidden behind a bench. These safety aids should be stored visibly and be easily accessible. ”
Source location
Graham Ian COOMBE · 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
Increase the ropes on all life-saving rings to 50 metres.

Verbatim wording from the response
“There are two life saving rings half way down the pier and three at the end of the pier, of which two are at each side and one is kept at the fishing tackle/fishermen’s shop. All rings are easily visible and accessible. The length of the ropes on the life saving rings has been increased to 50 metres.”

Source location
Response from Eastbourne Pier
Page 1 · response
Published 13 November 2023
Open published response
27 Feb2023
Bedfordshire and Luton
Concerns raised1
1. Unavailability of promptly accessible lifesaving equipment at the lakeside
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Install additional unlocked throw lines and accompanying safety signage near the high-water mark at Locations 5 and 7 and other previously affected locations.
  Stated by Forest of Marston Vale TrustStated planned
Respondent positions 3
1. Position
  The Trust considers its existing risk assessment and safety arrangements suitable and sufficient to address drowning risks.
  Stated by Forest of Marston Vale TrustExisting arrangements considered sufficient
1. Position
  The Trust disputes that locked throwlines were inaccessible, stating that children could obtain the access code through emergency services.
  Stated by Forest of Marston Vale TrustDisputes the concern
2. Position
  The Trust considers that changing lifesaving-equipment positioning would not have altered the fatal outcome in this case.
  Stated by Forest of Marston Vale TrustDisputes the concern
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
10 Apr2019
Brighton and Hove
Concerns raised1
1. Lack of police awareness of life-line locations and use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Distribute prompt cards showing Brighton and Hove coastal throw-ring locations to all divisional police officers and staff.
  Stated by Sussex PoliceStated completed
2. Action
  Introduce throw lines as standard equipment in marked Sussex Police Response and other marked police vehicles.
  Stated by Sussex PoliceStated completed
3. Action
  Implement the joint Surrey and Sussex policy, toolkit and guidance on water safety and throw-line use for first responders.
  Stated by Sussex PoliceStated completed
1. Action
  Add coastal throw-ring locations to the Sussex Police digital mapping system.
  Stated by Sussex PoliceStated planned
2. Action
  Require police CCTV operators to scan for water-safety equipment and highlight its location during initial responses to people believed in danger in water.
  Stated by Sussex PoliceStated completed
AI-generated summary

David DOOLEY · 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 DOOLEY died in an incident in the sea at Brighton seafront. The report identified that police officers did not know the location of nearby life lines, causing a delay in attempts to throw one, although it considered that adverse weather and sea conditions would have prevented an earlier successful rescue attempt. It also raised concerns about public awareness of the dangers of entering the sea after consuming alcohol or taking drugs, and the inquest concluded that the death was accidental.

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 police awareness of life-line locations and use
Wider context from the report
“(1) The exact location of the life lines on Brighton seafront were not known to the Police officers who attended the scene of the incident. Mr Dooley’s friend informed security at the local night club that he believed that Mr Dooley was in the sea and the police officers attended very quickly. The location of the life lines were not known to the police officers who attended the beach. A life line had to be brought from the Police Station. As a consequence, there was a delay in a life line being thrown to Mr Dooley. There was in fact a life line 30 metres from where Mr Dooley’s friend had first alerted the night club security that Mr Dooley was in the sea. Although there was a delay in attempts being made to throw Mr Dooley a life line, taking into consideration the adverse weather conditions (Storm Callum) and sea conditions, even if a line had been thrown earlier, I consider it would not have been able to be thrown to Mr Dooley successfully. (2) Steps should be taken to increase the police awareness of the location of life lines and their use, so that they can be used more expeditiously. ”
Source location
David DOOLEY · 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
Distribute prompt cards showing Brighton and Hove coastal throw-ring locations to all divisional police officers and staff.

Verbatim wording from the response
“2. Following this tragic incident the location of publically available throw lines and rings is more widely known among officers and staff. Acting on the recommendations of the Coroner’s report, prompt cards showing the location of the 25 throw rings currently provided by Brighton & Hove City Council have been obtained and have been sent to all Police officers and staff on Brighton & Hove Division.”

Source location
2019-0127-Response-by-Sussex-Police
Page 2 · response
Published 15 July 2019
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
Introduce throw lines as standard equipment in marked Sussex Police Response and other marked police vehicles.

Verbatim wording from the response
“4. Following on from previous action taken by Sussex Police in relation to water safety awareness and additional training for police officers and staff, ‘throw lines’ were purchased and made part of the standard equipment for all Sussex Police marked Response vehicles in August 2018. In November 2018 throw lines were also introduced as standard equipment on all marked police vehicles in Sussex. In early 2019 this was further enhanced with the introduction of the joint Surrey and Sussex force policy on ‘Water Safety for first responders’ (1184/2019). This policy document also includes a comprehensive toolkit for officers and staff, and also a guidance sheet on the effective use of the throw lines now available in all marked police vehicles.”

Source location
2019-0127-Response-by-Sussex-Police
Page 3 · response
Published 15 July 2019
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
Implement the joint Surrey and Sussex policy, toolkit and guidance on water safety and throw-line use for first responders.

Verbatim wording from the response
“4. Following on from previous action taken by Sussex Police in relation to water safety awareness and additional training for police officers and staff, ‘throw lines’ were purchased and made part of the standard equipment for all Sussex Police marked Response vehicles in August 2018. In November 2018 throw lines were also introduced as standard equipment on all marked police vehicles in Sussex. In early 2019 this was further enhanced with the introduction of the joint Surrey and Sussex force policy on ‘Water Safety for first responders’ (1184/2019). This policy document also includes a comprehensive toolkit for officers and staff, and also a guidance sheet on the effective use of the throw lines now available in all marked police vehicles.”

Source location
2019-0127-Response-by-Sussex-Police
Page 3 · response
Published 15 July 2019
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
Add coastal throw-ring locations to the Sussex Police digital mapping system.

Verbatim wording from the response
“As previously explained, there are 25 throw rings situated along the seafront of Brighton & Hove, the location of which have been mapped and recorded on prompt cards for Police officers and staff. The intention is to share this with the Brighton & Hove Crime Reduction Partnership which will include night time economy workers such as door staff. Although prompt cards have been provided to officers and staff showing the location of coastal throw rings, the longer term aim is to have these locations also available on our Sussex Police digital mapping system. There are some technical challenges but CI Bennett is engaged at the appropriate level and aims to finalise this by 1st September 2019.”

Source location
2019-0127-Response-by-Sussex-Police
Page 3 · response
Published 15 July 2019
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
Require police CCTV operators to scan for water-safety equipment and highlight its location during initial responses to people believed in danger in water.

Verbatim wording from the response
“Changes to our standard operating procedures within the Sussex Police Contact Centre will with immediate effect include police CCTV operators being tasked via police incident management system (“Webstorm”) to ‘scan’ for water safety equipment at the location of an incident, as part of the initial response where it is believed someone has entered the sea and is thought to be in danger. The wording that has been introduced as an automated prompt is ‘In incidents where a person has entered the water, on shore or inland, where there is a CCTV view, the identification of life saving equipment, such as throw lines, should be highlighted to attending officers/staff and members of the public who may have called on 999.’”

Source location
2019-0127-Response-by-Sussex-Police
Page 3 · response
Published 15 July 2019
Open published response
22 Jan2014
York City
Concerns raised1
1. Failure to protect river rescue equipment from vandalism and weather
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Paul Alan Rogerson · 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

Paul Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and 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
Failure to protect river rescue equipment from vandalism and weather
Wider context from the report
“(1) The position and protection of life buoys and throwing lines is inadequate. Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river. The integrity of this equipment is insufficiently protected from vandalism and the weather. ”
Source location
Paul Alan Rogerson · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of means for people to get out of the canal unaided

Actions described in response 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.1

Concerns raised2

Insufficient length of ropes attached to life-saving rings for reaching the water at low tide

Failure to keep life-saving rings visible and easily accessible

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

Concerns raised1

Unavailability of promptly accessible lifesaving equipment at the lakeside

Actions described in response 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.3

Concerns raised1

Lack of police awareness of life-line locations and use

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to protect river rescue equipment from vandalism and weather

Actions described in response 1

Respondent positions 1

Actions described in response 1

Actions described in response 1

Respondent positions 3

Actions described in response 5