Recurring concern

Inadequate controls for drowning risks at open-water locations

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First reported 22 Jan 2014•Latest report 26 Feb 2026

Definition

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.

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: 14
Individual concerns: 18
Date range: 2014–2026
Stated actions: 18

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 Trust2

Alexandra Park and Palace Charitable Trust1

British Mountaineering Council1

City of York Council1

Cornwall Council1

Department for Education1

Eastbourne Pier1

Foresight Group1

Network Rail1

North Yorkshire Council1

North Yorkshire Fire and Rescue Service1

North Yorkshire Police1

Park Holidays UK Limited1

Porthleven Harbour & Dock Company1

Royal Yachting Association1

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.

27 Feb2019
West Sussex
Concerns raised1
1. Inadequate warning signage at Lake entry areas
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 2
1. Action
  Install additional warning signs around the Park, increasing signage from eight to 24 signs, including signs at both accessible Lake edges.
  Stated by Park Holidays UK LimitedStated completed
2. Action
  Erect pictorial “no swimming” signs alongside existing written warning signs.
  Stated by Park Holidays UK LimitedStated planned
Respondent positions 2
1. Position
  The existing number and placement of warning signs are considered adequate to highlight deep-water dangers and prohibit swimming.
  Stated by Park Holidays UK LimitedExisting arrangements considered sufficient
1. Position
  Contractor competence checks, task-specific risk assessments, and existing signage are considered sufficient to address contractors’ awareness of lake rules.
  Stated by Park Holidays UK LimitedExisting arrangements considered sufficient
AI-generated summary

SHANE GRAY · 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

On 25 July 2018, Shane Gray entered Lythorne Lake for a swim after work, got into difficulties, and drowned. The concerns included inadequate warning signage, no physical barrier near an area intended for families with young children, text-only signage, and contractors not being directly informed of lake rules.

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
Inadequate warning signage at Lake entry areas
Wider context from the report
“(1) That there was inadequate signage in this particular area of the Site where Shane entered the Lake warning him that Swimming was not permitted. ”
Source location
SHANE GRAY · 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 additional warning signs around the Park, increasing signage from eight to 24 signs, including signs at both accessible Lake edges.

Verbatim wording from the response
“An Open Water Risk Assessment was carried out on 10 July 2018, before the incident. At that time, although extensive signage was in place at the Park, an action point was noted that the quantity of life rings and signage be reviewed. The new signage was ordered and delivered in August 2018 and was installed during August / early September. There are now 24 signs around the Park with two”

Source location
2019-0075-Response-by-Park-Holidays-UK
Page 1 · response
Published 9 June 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
Erect pictorial “no swimming” signs alongside existing written warning signs.

Verbatim wording from the response
“(3) The signage that is in place in other parts of the sites is in a text format (with no pictorial form) and therefore this signage does not provide for those individuals who cannot read or for children who are not of reading age”

Source location
2019-0075-Response-by-Park-Holidays-UK
Page 2 · response
Published 9 June 2019
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 existing number and placement of warning signs are considered adequate to highlight deep-water dangers and prohibit swimming.

Verbatim wording from the response
“signs on the Lake's edges, one on the "camp site side" and one on the opposing side along a designated pedestrian path. There are no signs along the edges that border the A27 due to the thick trees that border the lake/road.”

Source location
2019-0075-Response-by-Park-Holidays-UK
Page 2 · response
Published 9 June 2019
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
Contractor competence checks, task-specific risk assessments, and existing signage are considered sufficient to address contractors’ awareness of lake rules.

Verbatim wording from the response
“The Company carries out open water risk assessments for staff safety. These primarily relate to the Fisheries Wardens who do, on occasion, have need to access the water and/or lake edges. In this regard, the Company provides these wardens with life jackets to be used when undertaking such tasks. The Company does not agree that it would be practical to warn every contractor on site as to the dangers of the lakes, as a rule. The Company retains the services of contractors to carry out a number of different tasks, such as refuse collection and cleaning for example. It would be inappropriate to alert all contractors to all risks at the Park. Risk assessments are specific to the expected tasks and are only provided to staff who are to work directly on the lakes.”

Source location
2019-0075-Response-by-Park-Holidays-UK
Page 3 · response
Published 9 June 2019
Open published response
18 Jan2018
Inner South London
Concerns raised1
1. Failure to assess the safest site of entry to open water
This report raised 11 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

Master Abdul-Jamal Ottun · Prevention of Future Deaths report

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

Report summary

Master Abdul-Jamal Ottun, a 17-year-old school student, drowned while swimming in Shawnigan Lake, British Columbia, during a school rugby tour on 12 July 2015. The principal concerns were the adequacy of risk assessment and supervision, including the lack of consideration of a lifeguard, the risks of cold open water, the safest entry point, necessary equipment, and rescue arrangements.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess the safest site of entry to open water
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Dec2016
Dorset
Concerns raised1
1. Failure to wear a lifejacket or buoyancy aid when climbing over deep water
This report raised 4 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 2
1. Action
  Refresh website safety information pages, prominently featuring cold water shock guidance.
  Stated by Royal Yachting AssociationStated completed
2. Action
  Highlight safety information to members through electronic communications and the annual Safety Advisory Notice.
  Stated by Royal Yachting AssociationStated planned
Respondent positions 3
1. Position
  Wearing a lifejacket or buoyancy aid while climbing is impractical and may increase fall and neck-trauma risks.
  Stated by British Mountaineering CouncilDisputes the concern
1. Position
  Mountaineering falls outside the respondent’s remit, so it does not undertake responsive safety work for that activity.
  Stated by Royal Yachting AssociationOutside remit
2. Position
  Lifejackets, buoyancy aids and warm clothing could create significant hazards during climbing, increasing the likelihood of falling.
  Stated by Royal Yachting AssociationDisputes the concern
AI-generated summary

Liam Day · 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

Liam Day left home to go climbing on 15 June 2016 and failed to return; his body was recovered from the water on 28 June 2016, with the cause of death given as hypothermia following a fall into the sea. The report raised concerns about his lack of safety equipment, warm clothing, means of seeking help and specific plans, and highlighted the dangers of cold coastal water to people participating in water-based climbing activities.

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 wear a lifejacket or buoyancy aid when climbing over deep water
Wider context from the report
“Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:- 1. He was climbing with no safety line 2. He was not wearing a lifejacket or buoyancy aid 3. He was not wearing clothing that offered no warmth in the water 4. He was not on his own 5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio 6. He had left no specific instructions as to where he was intending to climb and what time he would be home The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report. During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight. ”
Source location
Liam Day · 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
Refresh website safety information pages, prominently featuring cold water shock guidance.

Verbatim wording from the response
“Within the sports that the RYA represents, the value of wearing a lifejacket or buoyancy aid and appropriate clothing is reasonably widely recognised. Nevertheless, the RYA has recently refreshed the safety information pages on its website (www.rya.org.uk/go/safety) and cold water shock appears prominently on the first page (under “look after yourself”). The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA’s annual Safety Advisory Notice.”

Source location
2016-0402-Response-by-RYA
Page 1 · response
Published 19 February 2017
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
Highlight safety information to members through electronic communications and the annual Safety Advisory Notice.

Verbatim wording from the response
“Within the sports that the RYA represents, the value of wearing a lifejacket or buoyancy aid and appropriate clothing is reasonably widely recognised. Nevertheless, the RYA has recently refreshed the safety information pages on its website (www.rya.org.uk/go/safety) and cold water shock appears prominently on the first page (under “look after yourself”). The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA’s annual Safety Advisory Notice.”

Source location
2016-0402-Response-by-RYA
Page 1 · response
Published 19 February 2017
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
Wearing a lifejacket or buoyancy aid while climbing is impractical and may increase fall and neck-trauma risks.

Verbatim wording from the response
“2. Wearing a lifejacket or buoyancy aid whilst climbing would not be practical, and due to its size and weight would likely increase the probability of the climber falling. A buoyancy aid could also present the added risk of neck trauma, as the climber would decelerate faster than if they were not wearing a buoyancy aid.”

Source location
2016-0402-Response-by-BMC
Page 1 · response
Published 19 February 2017
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
Mountaineering falls outside the respondent’s remit, so it does not undertake responsive safety work for that activity.

Verbatim wording from the response
“Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing”, and in fact increase the likelihood of the wearer falling.”

Source location
2016-0402-Response-by-RYA
Page 1 · response
Published 19 February 2017
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
Lifejackets, buoyancy aids and warm clothing could create significant hazards during climbing, increasing the likelihood of falling.

Verbatim wording from the response
“Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing”, and in fact increase the likelihood of the wearer falling.”

Source location
2016-0402-Response-by-RYA
Page 1 · response
Published 19 February 2017
Open published response
22 Jan2014
York City
Concerns raised1
1. Lack of a protocol for dealing with untidy or disordered rescue equipment
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
Lack of a protocol for dealing with untidy or disordered rescue equipment
Wider context from the report
“(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft. ”
Source location
Paul Alan Rogerson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate warning signage at Lake entry areas

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.2

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

Concerns raised1

Failure to assess the safest site of entry to open water

Concerns raised1

Failure to wear a lifejacket or buoyancy aid when climbing over deep water

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.2

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 a protocol for dealing with untidy or disordered rescue equipment

Actions described in response 2

Respondent positions 2

Actions described in response 2

Respondent positions 3