Recurring concern

Inadequate controls for drowning risks at open-water locations

First to latest report 22 Jan 2014 — 26 Feb 2026

Reports that mention this concern
14
Times this concern has been raised
18
Stated actions linked to this concern
18

What this concern includes

Includes failures of controls specifically dedicated to preventing, detecting or responding to drowning risks at open-water locations, including management of known water-entry points, barriers, hazard warnings, lighting, access restrictions, water-depth or condition information, rescue access and flotation or other life-saving equipment.

What is not included
  • Excludes generic premises, park or environmental safety deficiencies that are not specifically connected to drowning risk at an open-water location.
  • Excludes watercraft-specific hazards such as stoppers, towbacks or unsafe boating routes unless the assertion concerns the wider drowning-risk controls at the open-water location.
  • Excludes ordinary swimming, bathing or water-safety advice where no deficient control for a specific open-water drowning risk is identified.
  • Excludes isolated trip, visibility or access hazards that do not materially affect prevention of drowning or access to a person in hazardous water.

Reports and published responses 14 reports

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

  1. Cheshire

    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

  2. Manchester West

    AI-generated summary

    Alex Edward CROOK · 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

    Alex Edward Crook, aged 15, drowned after going out of his depth while playing at the edge of Scotsmans Flash on 7 September 2024. The concerns included failures to provide statutory swimming lessons, inadequate wording and siting of warning signs, and proposed siting of throw lines away from obvious water entry points.

    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 site throw lines at obvious water entry points

    Wider context from the report

    “It was established in evidence that throw lines are the most effective life-saving equipment. It was noted that the proposal is to locate these away from obvious entry points. This would seem to be likely to make them less effective than if they were sited at the more obvious entry points. The need for such equipment, as with the signage, is urgent. ”

    Source location

    Alex Edward CROOK · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to site water-safety signs close to obvious water entry points

    Wider context from the report

    “I am informed that signs have been erected as recently as 29 January 2025 at Scotsmans Flash yet these do not contain the words "no unauthorised swimming". It was agreed in evidence that if such signs were erected expeditiously close to the obvious entry points to the water, it might deter such use. ”

    Source location

    Alex Edward CROOK · 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 three throwline boards at the agreed locations, including one repositioned nearer likely swimming locations.

    Verbatim wording from the response

    “A Throwline board B Throwline board C Throwline board”

    Source location

    Response from Wigan Metropolitan Borough Council
    Page 3 · response
    Published 4 February 2025

    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

    Install enlarged warning and prohibition signs covering all viable approaches to Scotman’s Flash.

    Verbatim wording from the response

    “In respect of the signage, five signs have now been installed at Scotman’s Flash, which clearly and visibly warn the public of the dangers of deep water and cold-water shock. All viable approaches to Scotman’s Flash have now been covered by appropriate signage, these signs are much larger than previous signs. It was also agreed during the site inspection that supplementary prohibition signage including the wording “No unauthorised swimming or boating” will be added to the current signs. The prohibition signage has been produced and installed at Scotman’s Flash.”

    Source location

    Response from Wigan Metropolitan Borough Council
    Page 3 · response
    Published 4 February 2025

    Open published response

  3. Oxfordshire

    AI-generated summary

    Catherine Sarah Forbes · 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

    Catherine Forbes, aged 57, drowned after falling unwitnessed into the Thames and Kennet Marina late on 31 March 2023; she was unable to climb out using a nearby ladder. The principal concerns relate to the design, length, grip, number, placement and visibility of marina ladders, and to the availability of flotation devices, platforms and alarm systems to help people who fall into the water escape or raise the alarm.

    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 accessible flotation devices or water-surface platforms for marina self-rescue

    Wider context from the report

    “I am mindful that safety improvements have been made at the Thames and Kennet Marina, specifically in relation to risk assessment and ladders having been upgraded to 2m in length with a minimum of 1m beneath the water. This is welcomed, not least because Catherine Forbes was the third person to drown in similar circumstances at the marina since 2016. I have continuing industry wide concerns which, I believe, your organisation is in a position to take account of and review. I note from your response dated 28 May 2024 that British Marine and YHA are keen to ensure that marinas are as safe as possible. The particular concern is in relation to persons falling into the marina, on their own and unwitnessed, and what measures are in place to enable them to get out or raise the alarm. Perhaps the main issue relates to sufficiently designed ladders, in terms of length and grip, but also their number, placement and visibility from the water at day or night (flags, fluorescent signage, lighting for example). It is not for me to make recommendations and I am not an expert of course on marina safety but it is my duty to raise concerns that reflect the evidence heard at inquest and the issues helpfully raised by Ms Forbes family. With this in mind, I enquire if there are flotation devices or small platforms which sit on the surface of the water which a person could access more easily? I also enquire if there are alarm systems that exist or could be considered which can be activated from the water. I appreciate of course they would need to be non-electrical or non-battery or fully waterproof. Further, with regard to the Gold Anchor Award, it appears that the important issue of safety is not one of the key attributes or evaluation categories. Thames and Kennet held the top 5 Gold Anchors at the time of Ms Forbes death but were not fully compliant with the TYHA 2013 Code of Practice in relation to the length of all ladders. I note the 2013 Code is being reviewed from June 2024 and I enquire if the concerns raised in this report can be taken into account, in conjunction with designers and suppliers who the TYHA consult with. I can advise that I will be supplying a copy of this report to the HSE and also the organisation with oversight of District Council’s who often have responsibility for health and safety enforcement of marinas instead of the HSE. ”

    Source location

    Catherine Sarah Forbes · 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 reliable alarm systems activatable from the water

    Wider context from the report

    “I am mindful that safety improvements have been made at the Thames and Kennet Marina, specifically in relation to risk assessment and ladders having been upgraded to 2m in length with a minimum of 1m beneath the water. This is welcomed, not least because Catherine Forbes was the third person to drown in similar circumstances at the marina since 2016. I have continuing industry wide concerns which, I believe, your organisation is in a position to take account of and review. I note from your response dated 28 May 2024 that British Marine and YHA are keen to ensure that marinas are as safe as possible. The particular concern is in relation to persons falling into the marina, on their own and unwitnessed, and what measures are in place to enable them to get out or raise the alarm. Perhaps the main issue relates to sufficiently designed ladders, in terms of length and grip, but also their number, placement and visibility from the water at day or night (flags, fluorescent signage, lighting for example). It is not for me to make recommendations and I am not an expert of course on marina safety but it is my duty to raise concerns that reflect the evidence heard at inquest and the issues helpfully raised by Ms Forbes family. With this in mind, I enquire if there are flotation devices or small platforms which sit on the surface of the water which a person could access more easily? I also enquire if there are alarm systems that exist or could be considered which can be activated from the water. I appreciate of course they would need to be non-electrical or non-battery or fully waterproof. Further, with regard to the Gold Anchor Award, it appears that the important issue of safety is not one of the key attributes or evaluation categories. Thames and Kennet held the top 5 Gold Anchors at the time of Ms Forbes death but were not fully compliant with the TYHA 2013 Code of Practice in relation to the length of all ladders. I note the 2013 Code is being reviewed from June 2024 and I enquire if the concerns raised in this report can be taken into account, in conjunction with designers and suppliers who the TYHA consult with. I can advise that I will be supplying a copy of this report to the HSE and also the organisation with oversight of District Council’s who often have responsibility for health and safety enforcement of marinas instead of the HSE. ”

    Source location

    Catherine Sarah Forbes · 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

    Revise and update the Code of Practice using information about the drowning, including consideration of water-level devices and alarm methods.

    Verbatim wording from the response

    “Through these objectives and the following actions, TYHA aims to further enhance water safety standards across marinas and reduce the likelihood of similar tragedies in the future. The Code of Practice revision will consider the viability of water level devices to assist with self-rescue and methods of raising the alarm from the water.”

    Source location

    The Yacht Harbour Association
    Page 1 · response
    Published 19 November 2024

    Open published response

  4. Somerset

    AI-generated summary

    Peter Ivor Jeffery · 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

    Peter Ivor Jeffery, aged 68, entered the water at Burnham-on-Sea on 29 October 2023 to assist a stranger and her dog in distress and was overcome by a rip tide. He was unable to be rescued and his body was discovered near Stert Island on 12 November 2023. The report raises concerns that the risks of entering the water, including undercurrents and rip tides, were not prominently and clearly displayed to people without local knowledge, particularly outside the season when additional signage or flags were absent.

    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 prominently and clearly display water-entry risks and undercurrent and rip-tide dangers

    Wider context from the report

    “Whilst there are multiple signs in existence at the location, not all of these are for public safety, some focus on more ‘administrative’ matters such as the closure of gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly important in the smooth administration of the public space, the consequences of such are not life threatening and the size and prominence of such administrative signs and surprising when compared with the signage that conveys potentially life-saving information. I am concerned that the risks posed by entering the water (which appear equal to, if not greater than, the risks posed by the mud and sand) are not prominently and clearly displayed to those who lack local knowledge, especially out of ‘season’. This may cause people to misinterpret or underestimate the dangers posed by the undercurrent and rip-tides which, of course, are under the surface of the water and so not immediately obvious or visible. As such people may continue to make ill-advised decisions to enter the water; water which has the power and ability to overwhelm even the strongest of adult swimmers within seconds. ”

    Source location

    Peter Ivor Jeffery · 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

    Review safety signage provision at Burnham-on-Sea Jetty.

    Verbatim wording from the response

    “Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Install prominent entrance signage warning of strong currents and drowning or injury risks.

    Verbatim wording from the response

    “Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete lower-jetty line painting warning against access because of dangerous currents.

    Verbatim wording from the response

    “In addition, line painting is being completed on the lower part of the jetty advising against access stating “Dangerous Currents no Access””

    Source location

    Response from Somerset Council
    Page 2 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Install signage at the Jetty, including top-of-jetty signs and line markings on the tarmacked surface.

    Verbatim wording from the response

    “I refer to my letter dated the 11 November 2024. As discussed in my letter of the 11 November 2024 I have attached below details of the signage installed at the Jetty in Burnham on Sea. This work was completed in November 2024. This has involved signage being installed at the top of the jetty and line marked signage being applied to the tarmacked surface”

    Source location

    Updated response from Somerset Council
    Page 1 · response
    Published 19 September 2024

    Open published response

  5. East Sussex

    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 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

  6. 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

    Failure to manage known water-entry locations and rope-swing access hazards

    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 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of information about varying and sudden changes in water depth

    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 action was interpreted

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

    PFD Monitor interpretation

    Issue warm-weather warnings about lake access dangers to local schools for dissemination to pupils.

    Verbatim wording from the response

    “As well as installing the new throw lines and signage referred to above , the Trust has resolved to issue messages to local schools in periods of warm weather warning of the dangers of accessing the lake, and encouraging them to share this information with their pupils. This will supplement information already provided by the Trust via social media.”

    Source location

    Response from DAC Beachcroft
    Page 4 · 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

    Existing no-swimming and hidden-hazard signage is considered preferable to signs identifying individual deep-water areas.

    Verbatim wording from the response

    “The Trust has not seen the video footage referred to but is aware of this issue at very many points around the lake . This is one of several reasons why entering the water is forbidden . The risk of “Hidden Hazards” is specifically identified on safety signage around the lake. As indicated in our written submission the Trust’s view is that placing signs in the very many deep water areas will create the impression that those areas that not signage are somehow safe for swimming.”

    Source location

    Response from DAC Beachcroft
    Page 2 · response
    Published 10 March 2023

    Open published response

  7. 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 access ladders or a refuge area for people in the water

    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

    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

  8. North London

    AI-generated summary

    Connor Peter Marron · 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

    Connor Peter Marron was struck and fatally injured by a train on 2 January 2022 near Hornsey Railway Station after leaving a public house to return to Alexander Palace. Concerns included inadequate lighting and signage near the stream and railway fence, and a fence that was not adequate to prevent access to the railway track.

    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 signs identifying the stream, its depth and warnings of danger

    Wider context from the report

    “1. There was no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger. ”

    Source location

    Connor Peter Marron · 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 New River Path warning signage beside the location 1 kissing gate.

    Verbatim wording from the response

    “Location 1 has a kissing gate entrance to the New River path, with palisade fencing on either side in good condition. There is a small notice on the gate concerning right of access and entry at one’s own risk. However, the Thames Water standard hazard warning sign stating, ‘danger deep water, no swimming, no boating, no fishing’, which should be displayed at each access point to the river is not in place in this location. Arrangements have been made for this to be installed so it will mirror the signage at location 6 (see further comments below).”

    Source location

    Response from Thames Water
    Page 4 · response
    Published 22 September 2022

    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

    Lighting and signage at the stream and venue are matters for the relevant landowners, not Network Rail.

    Verbatim wording from the response

    “Addressing the matters set out in your report in turn, in relation to the first two matters listed we note that it states that there was “….no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger” and “….no signs in that area to assist with locating a way out from that part of the venue’s grounds”. The stream and venue referenced are not located on Network Rail land and therefore the provision of lighting and/or signage in those locations is a matter for the relevant landowners, whom Network Rail understands are Thames Water and Alexandra Palace. With regard to lighting beside the railway fence, it is not Network Rail policy to provide lighting along its fence line and, accordingly, lighting is not in place along this particular section of fencing.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 22 September 2022

    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

    Lighting along Network Rail’s fence line will not be provided because Network Rail policy does not require it.

    Verbatim wording from the response

    “Addressing the matters set out in your report in turn, in relation to the first two matters listed we note that it states that there was “….no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger” and “….no signs in that area to assist with locating a way out from that part of the venue’s grounds”. The stream and venue referenced are not located on Network Rail land and therefore the provision of lighting and/or signage in those locations is a matter for the relevant landowners, whom Network Rail understands are Thames Water and Alexandra Palace. With regard to lighting beside the railway fence, it is not Network Rail policy to provide lighting along its fence line and, accordingly, lighting is not in place along this particular section of fencing.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 22 September 2022

    Open published response

  9. West Yorkshire Eastern

    AI-generated summary

    Eliot Peter Burton · 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

    Eliot Peter Burton, aged 15, was found drowned at an unmanned hydroelectric plant after entering the site as a trespasser and falling into an outlet channel. The concerns included repeated trespassing by young people, deep uncovered channels with limited or no edge protection, difficult access to the site via the adjacent weir, and limited effective action to reduce the risks to children.

    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 deep water channels from falls

    Wider context from the report

    “3. There are deep uncovered channels on the site to conduct water through the facility. It is foreseeable that a trespasser would be in a precarious situation if they were to fall into the water, as Elliot Burton did. Many of the channels are uncovered, and /or have no edge protection. ”

    Source location

    Eliot Peter Burton · 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

    Add fence returns, mesh infills, warning signs, internal barriers, secure gates and practicable channel covers to deter unauthorised access.

    Verbatim wording from the response

    “2.3 In relation to access from the landside perimeter, we have added further fence panel returns and signage, we have also now had expert advice as to the use of galvanised metal spiked fans. Where practicable these will be used to deter persons from climbing around the edge of perimeter fence panels where they open on to the river and accessing ledges within the Facility. The objective is to make access difficult and unattractive to the Facility as a whole, and within it in relation to those areas where there are drops to deep and potentially fast flowing water. However, these measures must not create debris traps that import significant risk for those required to then remove debris and maintain the structures.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 2 · response
    Published 4 May 2021

    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

    Install galvanised steel fans and associated fencing to block access routes around the outlet channel, fish pass, downstream outlet and escape ladder.

    Verbatim wording from the response

    “3.12 With reference to access along the capping beam which encloses the outlet channel, we have had to balance the need for any structures to be robust so as to resist flood impact and also to be reasonably accessible for maintenance (for example through the use of hand tools). We will be installing a galvanised steel fan, bolted to the capping beam and spanning out over the outlet channel.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 3 · response
    Published 4 May 2021

    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

    Foresight disputes having controlled Yorkshire Hydropower Limited’s operations or constrained its director’s decisions regarding site safety.

    Verbatim wording from the response

    “As a responsible company, and in light of your concerns raised in the Regulation 28 report, we have reviewed the recordings of the evidence given to identify any steps required on Foresight's part. However we have identified nothing indicating that Foresight had control of YHL's operations, or that ████████ role with Foresight dictated or constrained his actions as a director of YHL.”

    Source location

    2021-0131-Response-from-Foresight-Group-Redacted
    Page 2 · response
    Published 4 May 2021

    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

    Operational and safety decisions, including preventing recurrence, are the responsibility of Yorkshire Hydropower Limited rather than Foresight.

    Verbatim wording from the response

    “Such operational decisions were, and are, decisions for YHL to make, entirely independent of Foresight, as these companies have separate legal personas. Any person holding a director role by virtue of Foresight's Investment Advisory Services contract is an employee of Foresight's business and a director of YHL. Any such individual is fulfilling two distinct roles, which are clearly delineated and do not afford Foresight any control over YHL, including how any director should have exercised their discretion as a director. Clearly any director has a statutory obligation to act only in the best interests of the company and not to vote on matters in which they had a conflict of interest.”

    Source location

    2021-0131-Response-from-Foresight-Group-Redacted
    Page 2 · response
    Published 4 May 2021

    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

    Covering the channels is not reasonably practicable because flooding, debris, maintenance access and potential escape hazards would introduce greater risks.

    Verbatim wording from the response

    “3.2 The use of fences and barriers within the Facility, as well as the covering of channels has to be considered in the context of debris entrapment and critically, access for those removing it. The force of the river and the substantial debris that collects can and has caused damage to the Facility, this is one of the major operational concerns in this dynamic environment.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 2 · response
    Published 4 May 2021

    Open published response

  10. North Yorkshire (Western)

    AI-generated summary

    MOHAMMED BILAL ZEB · 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

    MOHAMMED BILAL ZEB, aged 18, drowned after jumping into the River Wharfe at Linton Falls on 31 July 2020; he could not swim and became unresponsive. Concerns included the absence of flotation or rescue aids, difficult access and conditions for rescuers, and a lack of apparent safety warnings about hazards including cold water, water flow and underwater obstructions.

    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 safety warnings about unseen cold-water and water-flow hazards

    Wider context from the report

    “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident. (2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties. It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location. (3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels. ”

    Source location

    MOHAMMED BILAL ZEB · 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

    Unavailability of water-rescue aids at incident scenes

    Wider context from the report

    “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident. (2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties. It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location. (3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels. ”

    Source location

    MOHAMMED BILAL ZEB · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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