Recurring concern

Unreliable emergency water-rescue procedures and equipment

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First reported 22 Jan 2014•Latest report 7 Sep 2023

Definition

What this concern includes

Includes failures of emergency water-rescue arrangements for police, ambulance, fire or comparable responders, including recognition and application of established rescue procedures, responder training or awareness, availability and issue of throw lines or comparable rescue equipment, and other controls specifically dedicated to reaching or rescuing people from water.

Not included

  • Excludes water-rescue arrangements limited to recreational water activities, which are covered by the more specific recreational water-rescue concern.
  • Excludes generic emergency-response, first-aid or communication deficiencies unless they directly impair emergency water rescue.
  • Excludes general drowning hazards, water-safety warnings, lifeguard provision and watercraft-operation controls unless the assertion specifically concerns emergency responder water-rescue arrangements.
  • Excludes failures occurring after a person has been safely recovered when the emergency water-rescue process itself was not deficient.
Reports
3

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

City of York Council1
Metropolitan Police Service1
North Yorkshire Council1
North Yorkshire Fire and Rescue Service1
North Yorkshire Police1
Yorkshire Dales National Park Authority1
Yorkshire Water Services Limited1

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.

  1. North London

    AI-generated summary

    Lamont Ashley Roper · 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

    Lamont Ashley Roper was found dead at the bottom of Lock 17 after entering the canal following a cycling pursuit, a stop-and-search request, and a struggle with a police officer near the canal railings. The concerns included the availability of water-rescue equipment and resources, access to specialised divers, and the risks and training associated with police cycle patrols and pursuits near bodies of water.

    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 suitable water rescue equipment for officers patrolling near bodies of water

    Wider context from the report

    “1. The Coroner recommends to the MPS that they consider whether there is any alternative and less cumbersome water rescue equipment [to throw lines] that could be issued to officers on patrol near bodies of water, for example some sort of device which could be inflated quickly and thrown to the person in the water to assist them in floating until a throw line is available. ”

    Source location

    Lamont Ashley Roper · 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 provide throw lines on all marked emergency vehicles

    Wider context from the report

    “5. The Coroner recommends that [throw lines] must be available and issued to all MPS marked emergency vehicles. ”

    Source location

    Lamont Ashley Roper · Prevention of Future Deaths report
    Page 3 · 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 factor water rescue equipment availability into dynamic patrol risk assessments

    Wider context from the report

    “3. The coroner recommends to the MPS to implement a requirement for officers conducting pre-planned operations along stretches of a canal or other bodies of water to make themselves aware of the availability (or non-availability) of water rescue equipment in order for this to be factored into their ongoing dynamic risk assessment whilst on patrol” ”

    Source location

    Lamont Ashley Roper · 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

    Insufficient number of qualified divers available to police

    Wider context from the report

    “6. The Coroner makes a recommendation that steps should be taken to increase the number of qualified divers available to the police to assist with the respond to an incident. ”

    Source location

    Lamont Ashley Roper · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue working with water-rescue stakeholders to consider viable future technologies for police officers.

    Verbatim wording from the response

    “In addition, the MPS Public and Personal Safety Unit (“PPSU”) has scoped the current marketplace to ascertain if there are any viable alternatives that would offer carriage of water rescue equipment on the person. No product has currently been identified which would overcome the issues previously outlined, i.e. the cumbersome product design and weight that would have to be additionally factored in. The PPSU will continue to work with stakeholders with key responsibilities in water rescue, to consider the viability in the use of future technologies for use by police officers in such circumstances.”

    Source location

    Response from Metropolitan Police Service
    Page 2 · response
    Published 30 October 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

    Require Basic Command Units to establish management arrangements for deploying, using, and maintaining throw lines.

    Verbatim wording from the response

    “• Basic Command Units are to establish system management for the deployment, use and maintenance of throw lines.”

    Source location

    Response from Metropolitan Police Service
    Page 3 · response
    Published 30 October 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

    Provide throw-line access for officers conducting pre-planned operations near bodies of water.

    Verbatim wording from the response

    “Officers either specifically tasked with patrols by bodies of water, or part of planned operations, are required to have a throw line available to them. This may extend to access from a nearby vehicle.”

    Source location

    Response from Metropolitan Police Service
    Page 3 · response
    Published 30 October 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

    Continue reviewing and assessing police dive-team size against threat, harm, risk, and demand.

    Verbatim wording from the response

    “The MPS Taskforce Command constantly review and assess team sizes based on the threat, harm and risk balanced with the demand. At this time, the assessment is that there is sufficient police dive team capacity to meet its demand.”

    Source location

    Response from Metropolitan Police Service
    Page 5 · response
    Published 30 October 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 Marine Policing Unit is not responsible for rescuing people in difficulty in water.

    Verbatim wording from the response

    “In response to the Coroner’s matter of concern, whilst it is not the responsibility of the MPS Marine Policing Unit to rescue persons who are in difficulty in water, officers will seek to identify water rescue equipment which is easily accessible when such spontaneous incidents arise or when patrolling near bodies of water. This includes throw lines, which are retained in every MPS marked emergency vehicle.”

    Source location

    Response from Metropolitan Police Service
    Page 2 · response
    Published 30 October 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

    No viable wearable water-rescue equipment alternative has been identified because product weight and cumbersome design remain barriers.

    Verbatim wording from the response

    “In addition, the MPS Public and Personal Safety Unit (“PPSU”) has scoped the current marketplace to ascertain if there are any viable alternatives that would offer carriage of water rescue equipment on the person. No product has currently been identified which would overcome the issues previously outlined, i.e. the cumbersome product design and weight that would have to be additionally factored in. The PPSU will continue to work with stakeholders with key responsibilities in water rescue, to consider the viability in the use of future technologies for use by police officers in such circumstances.”

    Source location

    Response from Metropolitan Police Service
    Page 2 · response
    Published 30 October 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

    Throw lines in marked emergency vehicles are considered to mitigate cycle patrol officers’ lack of immediate access to rescue equipment.

    Verbatim wording from the response

    “The circumstances of cycle patrol are the same as those of general patrol duties, in that they are not planned taskings or operations. Throw lines are now available in all marked emergency vehicles which mitigates the risk of officers on foot or cycle patrols having ready access to this provision.”

    Source location

    Response from Metropolitan Police Service
    Page 3 · response
    Published 30 October 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

    Officers on pre-planned operations near water are already required to have access to throw lines under the Water Intervention Risk Assessment.

    Verbatim wording from the response

    “As above, officers conducting pre-planned operations along bodies of water, are now required to have access to throw lines which is covered in the MPS Water Intervention Risk Assessment.”

    Source location

    Response from Metropolitan Police Service
    Page 3 · response
    Published 30 October 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 RNLI, London Fire Brigade and UK Coastguard have the relevant expertise and responsibilities for water rescue.

    Verbatim wording from the response

    “Other agencies, such as the RNLI, LFB and the UK Coastguard have the relevant expertise and responsibilities in water rescue.”

    Source location

    Response from Metropolitan Police Service
    Page 5 · response
    Published 30 October 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 existing police dive team is assessed as having sufficient capacity to meet demand.

    Verbatim wording from the response

    “The MPS Taskforce Command constantly review and assess team sizes based on the threat, harm and risk balanced with the demand. At this time, the assessment is that there is sufficient police dive team capacity to meet its demand.”

    Source location

    Response from Metropolitan Police Service
    Page 5 · response
    Published 30 October 2023

    Open published response
  2. 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

    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
  3. York City

    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

    Insufficient police familiarity with current Fire and Rescue water rescue methods

    Wider context from the report

    “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue. ”

    Source location

    Paul Alan Rogerson · 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

    Insufficient police training in current river rescue and water safety protocols

    Wider context from the report

    “(3) North Yorkshire Police Officers may require further training in current protocols for River Rescue and Water Safety. ”

    Source location

    Paul Alan Rogerson · 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 a system for reporting missing life buoys

    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
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Data last updated 7 September 2026