Recurring concern

Failure to prevent public access to closed or restricted hazardous sites

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First reported 4 Mar 2014•Latest report 6 Mar 2026

Definition

What this concern includes

Includes failures of dedicated controls intended to prevent or restrict public access to hazardous or officially closed sites, including fencing, gates, locks, barriers, security arrangements, access monitoring and timely implementation of closure measures where the site is not intended for public access.

Not included

  • Excludes ordinary public access to sites that are open and intended for public use, even where general safety measures are needed.
  • Excludes the underlying drowning, fall, electrical or other site hazard when no failure to control public access is identified.
  • Excludes general site-security or perimeter-maintenance deficiencies without a hazardous or restricted-site public-access context.
  • Excludes failures limited to warning information, route guidance or signage where access prevention or restriction is not the shared unsafe condition.
Reports
16

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
27

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.

Network Rail6
National Highways2
Borough Council of King's Lynn and West Norfolk1
British Transport Police1
Canal & River Trust1
Cornwall Council1
Durham County Council1
Foresight Group1
High Commission of Saint Lucia in the United Kingdom1
London North Eastern Railway Limited1
Luton Borough Council1
Norfolk Constabulary1
Norfolk County Council1
Porthleven Harbour & Dock Company1
Recipient name withheld1

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. County Durham and Darlington

    AI-generated summary

    Kay Wilson · 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

    Kay Wilson drowned shortly after 23:30 on 6 December 2025 after accidentally passing through a gap in a protective stone wall near County Bridge in Barnard Castle, falling approximately 9 metres onto rocks and then into the River Tees. The principal concern was that the breach provided unrestricted and unguarded access from a public area to the vertical drop and river below.

    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 prevent unrestricted and unguarded public access to a vertical drop

    Wider context from the report

    “A breach in the stone wall running north above the riverside from the east side of “County Bridge", Barnard Castle, provides unrestricted and unguarded access from a public area to a vertical drop of approximately 9 metres onto rocks and the River Tees below. ████████ ”

    Source location

    Kay Wilson · 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 a steel fence section to close the riverside wall gap and prevent unrestricted access to the drop.

    Verbatim wording from the response

    “• In relation to the breach in the stone wall running north above the riverside from the east side of "County Bridge" it has been agreed that the most appropriate permanent control measure is the installation of a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below.”

    Source location

    2026-0132 - Response from Durham County Council
    Page 2 · response
    Published 7 May 2026

    Open published response
  2. County Durham and Darlington

    AI-generated summary

    Jody Lee ROBB · 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

    Jody Lee ROBB died at 23:03 on 8 April 2025 on the carriageway of Station Approach after taking deliberate steps to end her own life. Concerns included insufficiently restricted access from the station platform and the possibility that her presence was not detected or reported by train crews or station staff, despite 11 trains passing during the preceding hour.

    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 physical barriers or impediments preventing public access from the platform to the hazardous area

    Wider context from the report

    “I read and heard evidence from the investigating CID officer who had reviewed all available CCTV in relation to the incident. She reported that Jody had arrived on the south bound platform just over an hour before she jumped. She sat on a bench for a few minutes before making her way onto ████████. She was on the ████████ for about one hour before she actually did so. A total of 11 trains passed her, north and southbound, during that hour. No report was made or received of her presence there by train crews of station staff attending on the station platforms for arrivals and departures. ████████. My concerns are: 1. Access to the ████████ from the platform is not sufficiently barred or impeded to the public. It is clear by means of signage that the public must not go beyond the end of the platform. There are what appear to be some sort of wheeled access steps overs on the platform at and around the fence at its end. But there is nothing to prevent even a moderately mobile person from going around the fence and ████████. The main resource preventing access is human by means of station staff intervention, which is necessarily reliant on their presence at the relevant time; 2. ████████ are not ones designed to prevent, impede or discourage attempts at suicide ████████████████████████████████████████████████████████████████ 3. Eleven trains passed Jody, from north and south, while she was on ████████ during the hour before she jumped. No reports were made by any train crew of her presence. It would be exceedingly the available evidence and unfair to infer that train crews and/or station staff deliberately or negligently ignored her presence there. More likely is that she was simply not visible. It was dark, being at night in April, and Jody was wearing relatively dark clothing. However, she seems to have been discernible on CCTV and from the British Transport Police images I have seen taken from approximately where a driver might have been placed, it is plausible to suggest that she might have been visible, even laterally, from the cab of a train either slowing to stop at the station or pulling out from it, even in deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her presence, some type of intervention could have been attempted ████████████████████ ████████. ”

    Source location

    Jody Lee ROBB · 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

    Provide a locked, climb-resistant gate restricting unauthorised access from the platform toward the track and viaduct.

    Verbatim wording from the response

    “The end of the platform is fitted with a locked gate, and beyond this, there is a drop off the edge of the platform to track level, to deter individuals from walking beyond the platform’s edge and onto the track. Access via the locked gate is granted only for authorised personnel. The gate is the standard design and has pointed tops, to make it difficult for individuals to climb over the gate. The gate does not extend to the platform edge, as this is in compliance with Network Rail’s national standards.”

    Source location

    2025-0330 Response from Network Rail
    Page 1 · response
    Published 14 July 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 anti-trespass rubber pyramid mats along the track and viaduct edges as physical and visual deterrents.

    Verbatim wording from the response

    “Near the end of the platform and at the side of the gate referred to above there are anti-trespass rubber pyramid mats (“witches hats”) which extend along the edge of the railway track onto the viaduct for approximately 60 metres, on each side of the station platform. This is beyond what is required by Network Rail’s standards. The intention of the witches hats is to make access difficult for anyone intending to trespass by acting as both a physical and visual deterrent.”

    Source location

    2025-0330 Response from Network Rail
    Page 1 · response
    Published 14 July 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

    Operate an automatic warning message directing people away from the platform end.

    Verbatim wording from the response

    “There is an automatic voice message released from a speaker, when individuals get within 14 metres of the end of the platform. This tells people to move away from the platform end.”

    Source location

    2025-0330 Response from Network Rail
    Page 1 · response
    Published 14 July 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

    Develop and secure remaining approval for mesh safety panels to increase and curve the viaduct parapet inward.

    Verbatim wording from the response

    “As the viaduct is a Grade 2 listed structure, Network Rail is required to submit a listed building consent application and prior approval planning application before it can undertake any work to physically alter the existing viaduct structure. Without the Council’s approval, we would be unable to carry out any works to the existing viaduct structure which alter its appearance.”

    Source location

    2025-0330 Response from Network Rail
    Page 2 · response
    Published 14 July 2025

    Open published response
  3. Manchester South

    AI-generated summary

    Alexander Charles Edward Thomas · 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

    Alexander Charles Edward Thomas died on 14 August 2024 after entering the eastbound carriageway of the M56 motorway and being struck by a heavy goods vehicle. Concerns included accessible routes from a pedestrian walkway and track to the motorway's crash barrier, and a lack of fencing to prevent access onto the motorway along that stretch.

    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 fencing preventing access over the eastbound motorway crash barrier

    Wider context from the report

    “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway. 2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway. 3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway. ”

    Source location

    Alexander Charles Edward Thomas · 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 prevent access from the pedestrian walkway to the eastbound motorway crash barrier via a ramp-like structure

    Wider context from the report

    “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway. 2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway. 3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway. ”

    Source location

    Alexander Charles Edward Thomas · 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

    Repair and extend boundary fencing around the hotel car park, Hasty Lane and the structure’s wing walls to reduce access to the carriageway.

    Verbatim wording from the response

    “We will repair the boundary fence both at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure to increase the security and reduce access to the area along the carriageway. This work will be completed by the 30 June 2025.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 16 January 2025

    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

    Completely preventing determined pedestrian access to the Strategic Road Network is impossible, although fencing and compliant design provide deterrence and security.

    Verbatim wording from the response

    “The M56 motorway at this point spans Hasty Lane which forms an underpass to facilitate access by cyclists and pedestrians. The structural supports and cast concrete wing walls mirror the profile of the embankments on either side of the motorway and are located within the highway boundary. This design of ‘bridge’ complies with the design requirements outlined within the Design Manual for Roads and Bridges and includes tubular railings to protect against falls from the structure. It is accepted that this type of design does not deter determined attempts by pedestrians to gain access to the motorway but when combined with timber boundary fence provides some deterrence and security. By the very nature of the Strategic Road Network, it is impossible to fully deny access.”

    Source location

    Response from National Highways
    Page 1 · response
    Published 16 January 2025

    Open published response
  4. 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

    Failure to close the pier to public access when unsafe conditions are present

    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 action was interpreted

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

    PFD Monitor interpretation

    Consider the event organiser’s response before permitting the event to proceed, ensuring reasonable precautions are in place.

    Verbatim wording from the response

    “The SAG are awaiting a response from the event organiser in relation to what additional measures are planned for this year following the tragic death, including safety measures for the harbour area and the sale of alcohol. The response will be supported by attendance at a SAG, so that all agencies have an opportunity to speak directly with the event organiser. The response will be considered by the members of the SAG prior to the event going ahead to ensure that reasonable precautions are in place.”

    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

    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

    The Festival is responsible for health and safety matters during festival events, working with Cornwall Council’s Health and Safety team.

    Verbatim wording from the response

    “We work very closely with the Porthleven Food Festival and have done since the Festival’s inauguration 15 years ago. Each year, Porthleven Harbour & Dock Company grants a right for the Festival to use the Harbour Head, the Shipyard and other areas within the Inner Harbour over the 2-3 days of the festival. This is granted on the basis that the Festival take responsibility for all health and safety matters, and to that end, they work closely with Cornwall Council Health & Safety team to put these measures in place. In the 15 years since the Festival was established, we are not aware of any major incidents or injuries and certainly no persons entering the water even though alcohol is a feature of the Festival.”

    Source location

    Response from Porthleven Harbour Dock Company
    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

    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

    Event organisers and Porthleven Harbour & Dock Company are responsible for temporary measures addressing increased festival risks at the pier.

    Verbatim wording from the response

    “The organisers may need to put in place temporary control measures in order to address the increased risk in particular areas. If there is a temporary increased risk at the pier area, it would be for the Event Organiser and Porthleven Harbour & Dock Company to take action to address it. As it does not relate to the crabbing operation but to the festival, enforcement of temporary measures would fall to the EHO and licensing office for enforcement.”

    Source location

    Response from Health and Safety Executive
    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

    Cornwall Council’s Environmental Health and licensing offices are responsible for enforcing temporary measures for festival-related increased risks.

    Verbatim wording from the response

    “For festivals and other events where paid work exists, there is a work activity and the Health and Safety at Work etc. Act 1974 applies. HSE has no vires in relation to festivals, other public events or to the bars/cafes with seating near to the harbour edge. The vires falls to the Local Authority, in this case the licensing arm of Cornwall Council and their Environmental Health Office (EHO). It is appreciated that such events may increase the health and safety risks, in particular the risk of falls, at the harbour and pier. It will be for the event organiser and Porthleven Harbour & Dock Company to convince the EHO and the licensing office, that have taken sufficient action to address the increased risk of a fall to danger occurring during the festival due to an influx of people, alcohol and low lighting converging near to or having access to open edges.”

    Source location

    Response from Health and Safety Executive
    Page 2 · response
    Published 28 February 2023

    Open published response
  5. 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

    Insufficient prevention of access to the site via the adjacent weir

    Wider context from the report

    “4. Despite perimeter fencing, it is known that one route for children to gain entry to the site is by crossing the River Calder at the Kirkthorpe weir adjacent to the site. There are few, if any impediments to prevent access to the weir from the river bank opposite the site. ”

    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

    Revise the west-bank risk assessment and erect fenced barriers to restrict access to the weir and water’s edge.

    Verbatim wording from the response

    “2.5 In January 2020 the Council revised the risk assessment for the west bank. This resulted in not only replacing numerous signs, but we also erected several new fenced barriers in attempt to improve safety and restricting access to the Weir and waters’ edge. The fencing construction at that time was limited. This area is heavy in vegetation, trees and swathes of wild Japanese knotweed. It has therefore been a very challenging environment to place physical barriers successfully.”

    Source location

    2021-0131-Response-from-Wakefield-Council-Redacted
    Page 3 · 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

    Progress detailed design, approvals, procurement and construction of a physical riverside barrier protecting the Yorkshire Hydro Plant perimeter.

    Verbatim wording from the response

    “1.3 The current strategy and plans are to undertake comprehensive physical works and construction projects. This is with aim to design and build robust physical barriers in the challenging and changing environments on the embankments adjacent the Kirkthorpe Weir. The result will be to prevent as far as reasonably practicable, trespass to the Yorkshire Hydro Plant and access to the Weir on both sides of the river in this locale. This project is working in Partnership with the Yorkshire Hydro Plant – Foresight Group (YHP) and the Canals and River Trust (CRT). Wakefield Council have also been working in close liaison with the Health and Safety Executive from the outset of this case.”

    Source location

    2021-0131-Response-from-Wakefield-Council-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

    Develop and procure approximately 300 metres of west-bank fencing with robust signage, conservation information boards and a safe viewing platform.

    Verbatim wording from the response

    “3.6 Phase 3 is running in parallel to Phase 2. This is a solely Council led initiative, the concept of which was supported by the HSE. This is to add further fenced protection to the west bank of the river based on our revised risk assessment of the site.”

    Source location

    2021-0131-Response-from-Wakefield-Council-Redacted
    Page 4 · 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

    Continue engaging with Yorkshire Hydropower Limited and Wakefield Metropolitan District Council to address shared risks and implement appropriate control measures at Kirkthorpe Weir.

    Verbatim wording from the response

    “The Trust has and continues to proactively engage with the other parties involved (YHL and WMDC) in relation to shared risks at Kirkthorpe Weir and the implementation of control measures as appropriate.”

    Source location

    2021-0131-Response-from-from-Canal-River-Trust-Redacted
    Page 1 · 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

    Commission a detailed options report and develop an agreed design for a barrier at the weir and sluice-gate interface.

    Verbatim wording from the response

    “4.2 The sluice gates and weir are not on land which is owned or controlled by YHL. Since the tragic incident YHL has sought to engage with the relevant parties to consider whether it is feasible to construct an additional barrier on or around these structures where they interface with the Facility. YHL does not have the authority to take action unilaterally in relation to any such works.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 4 · 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

    Support procurement and continue necessary design and procurement input while facilitating construction of the riverside barrier.

    Verbatim wording from the response

    “4.4 YHL are supporting WMDC in the procurement process for the steel works while the planning application is being reviewed.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 4 · 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

    Some proposed river barriers were rejected because their designs could create foreseeable risks or fail in flood conditions.

    Verbatim wording from the response

    “2.6 During this time, consultation with all 3 parties and the HSE were looking at the more challenging aspect of preventing trespass to YHP from the river and particularly gaining access by members of the public traversing the Weir. Several engineering solutions were considered each with their own difficulties with construction in a fast flowing river. Some solutions were dismissed. They may have prevented trespass, but their inherent design upon scrutiny, potentially caused other foreseeable risks. Other solutions may not have withstood flood waters.”

    Source location

    2021-0131-Response-from-Wakefield-Council-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

    Physical safety measures are constrained by the weir’s listed status, required planning approvals, ecological considerations and the need to protect habitats.

    Verbatim wording from the response

    “2.7 Further challenges to enable physical measures more quickly have been that the Weir construct itself is a listed structure. As such conservation planning consents and change to consider Historic England Planning approvals. Ecological factors have also had to be considered in terms of the fish passes on the Weir for example, and DEFRA generally. This impacts on the final”

    Source location

    2021-0131-Response-from-Wakefield-Council-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

    Construction timing is constrained by river conditions, including a requirement not to undertake works during flooding.

    Verbatim wording from the response

    “3.2 There are 3 Phases of work associated with the safety works at Kirkthorpe Weir. Phase 1 has been the measures taken to date as noted. Phase 2 is a joint approach to design a suitable physical barrier to the perimeter of the YHP site on the river side. The concept of this has been in the feasibility and design stages since June 2020, with the first designs suggested in October 2020.”

    Source location

    2021-0131-Response-from-Wakefield-Council-Redacted
    Page 4 · 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

    The Yorkshire Hydro Plant owners are responsible for security and perimeter management of their leased plant, buildings and operational area.

    Verbatim wording from the response

    “2.1 Wakefield Council has taken a significant lead in formulating a safety strategy for the area surrounding Kirkthorpe Weir. The Council owns the land on both sides of the river at this point. The west bank is part of the area known as the Southern Washlands and has nearby fishing lakes, country side walks and public footpaths. The east bank is the location of the YHP Plant. The plant owners lease the land, but have full responsibility as occupier for their own construction, operations and buildings with demise. This includes their security and perimeter management. CRT have ownership of approximately half of the Victorian weir construct. The council own the other half - but CRT take responsibility for its upkeep and general maintenance. The waterway”

    Source location

    2021-0131-Response-from-Wakefield-Council-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

    The Canals and Rivers Trust is responsible for upkeep and maintenance of its weir structure and the waterway.

    Verbatim wording from the response

    “2.1 Wakefield Council has taken a significant lead in formulating a safety strategy for the area surrounding Kirkthorpe Weir. The Council owns the land on both sides of the river at this point. The west bank is part of the area known as the Southern Washlands and has nearby fishing lakes, country side walks and public footpaths. The east bank is the location of the YHP Plant. The plant owners lease the land, but have full responsibility as occupier for their own construction, operations and buildings with demise. This includes their security and perimeter management. CRT have ownership of approximately half of the Victorian weir construct. The council own the other half - but CRT take responsibility for its upkeep and general maintenance. The waterway”

    Source location

    2021-0131-Response-from-Wakefield-Council-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

    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

    Responsibility for installing deterrent fencing on land not owned or managed by the Trust rests with WMDC and other involved parties.

    Verbatim wording from the response

    “There have been a number of meetings between the Trust (myself attending) and representatives of WMDC and YHL. We have discussed the risks and potential mitigations, and the outcome of those discussions is a proposal to install a fence at the interface between the hydroplant and the sluice gates. This would be on land not owned or managed by the Trust, though the Trust is a”

    Source location

    2021-0131-Response-from-from-Canal-River-Trust-Redacted
    Page 1 · 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

    The weir and sluice gates are not owned or controlled, and unilateral action to install barriers there is outside the authority available.

    Verbatim wording from the response

    “4.1 The route used by Elliot to access the Facility was to walk across the weir from the bank opposite, climb over the sluice gate structure and over a timber fence. The sluice gates (which are a listed structure) and the weir substantially predate the construction of the Facility.”

    Source location

    2021-0131-Response-from-Yorkshire-Hydropower-Limited-Redacted
    Page 4 · 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

    Wakefield Metropolitan District Council leads construction of the barrier at the weir and sluice gates through completion.

    Verbatim wording from the response

    “4.3 YHL has been part of a working group with WMDC and CRT since before the inquest. YHL commissioned a detailed options report which formed the basis of the final design, agreed by the group, for a barrier at this location. The details of that design have been submitted by WMDC to the local planning authority.”

    Source location

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

    Open published response
  6. County Durham and Darlington

    AI-generated summary

    Clive OXLEY · 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

    Clive OXLEY entered the track at Durham railway station, climbed the viaduct parapet, and jumped onto North Road below. Concerns included whether the pedestrian barrier adequately prevented access to the track and whether gaps and limited coverage in the wire fence enabled access to the parapet; two similar incidents were also noted.

    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 construction of the barrier preventing pedestrian access to the track

    Wider context from the report

    “1) It is accepted that the barrier to pedestrian traffic between the southbound platform and the viaduct makes it clear that pedestrians should not access the viaduct from the platform (as does the automatic voice alert which is activated as the barrier is passed). However, I am concerned that the barrier itself is not of a construction adequate to prevent a determined pedestrian such as the deceased from accessing the track at that particular point. ”

    Source location

    Clive OXLEY · 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

    Provide platform-end gates and fencing at higher-risk locations to restrict unauthorised access to the railway.

    Verbatim wording from the response

    “In order to make suicide and trespass as difficult as possible, platform end gates and fencing is provided, and prioritised at locations deemed higher risk to prevent access to the line wherever possible. With specific regards to Durham, this is supported by signage promoting services offered by the Samaritans and the warning system that is in place at the Station. In addition, LNER have trained a significant number of staff in suicide risk who are given guidance and training in dealing with vulnerable people when they are seen on the rail network.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 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

    Contact Network Rail to seek a joint site visit assuring that the fencing meets rail-industry standards.

    Verbatim wording from the response

    “LNER have made contact with Network Rail with a view to arranging a joint site visit in order to seek assurance that the fencing meets the requirements of the rail industry standards.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 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

    Complete southbound platform-end alterations, including a lockable gate, robust obscuring fence, audible warning, signage and anti-trespass flooring.

    Verbatim wording from the response

    “As part of that exercise, in December 2019, we undertook significant alteration to the end of the southbound platform to deter pedestrian access and to obscure the view of the viaduct from the platform. This was done by removing the sloped nose of the platform and installing a lockable gate and robust fence at the platform end. The fence itself is 1.8 metres high with a coarse infill to limit any view of the viaduct from the platform. The platform end also has an audible warning system, signage making clear that pedestrians are prohibited from passing the end of the platform and Samaritans signage. Anti-trespass flooring was also installed either side of the fencing the full width of the platform to further discourage pedestrians from passing the fence.”

    Source location

    2020-0301-Response-from-Network-Rail-Redacted
    Page 1 · response
    Published 8 January 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

    Network Rail is generally responsible for platform end and boundary fencing beyond LNER’s day-to-day station management.

    Verbatim wording from the response

    “LNER work collaboratively with Network Rail to reduce the number of trespass and fatality incidents along the LNER line of route, though in practical terms, LNER operate Durham Station under a long-term lease and are generally responsible for the day to day management of the Station. Platform end fencing and general boundary fencing in place to prevent unauthorised access to the track and other infrastructure is generally the responsibility of Network Rail.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 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

    A full-width southbound platform fence cannot be installed because mandatory gauging standards prohibit it.

    Verbatim wording from the response

    “Decisions in relation to the location and design of these measures took into account Network Rail’s relevant mandatory standards. Standards prohibit fencing to be constructed the full width of the platform due to gauging requirements (i.e. the need to consider the potential for a train to come into contact with the fence when passing the platform). The fence has been placed as far along the platform as standards allow. Consideration was also given to a derogation from standards but it was recognised that a determined individual could in any event access the track by climbing down from the platform edge.”

    Source location

    2020-0301-Response-from-Network-Rail-Redacted
    Page 1 · response
    Published 8 January 2021

    Open published response
  7. Bedfordshire and Luton

    AI-generated summary

    Ibrahima YAHAIA · 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

    Ibrahima YAHAIA, who had memory issues and was a French non-English-speaking national, was fatally struck by a bus while walking along the designated busway in Luton on 15 January 2020. The concerns included unrestricted pedestrian access to the busway, gaps in fencing and inadequate signage, previous serious incidents, alleged design flaws, and no evidence of steps to prevent further injuries or deaths.

    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 prevent pedestrian access to Busway lanes

    Wider context from the report

    “(1) There is a pedestrian footway which runs parallel to the Busway in places and pedestrians have access to the Busway at bus stops. Pedestrians may cross the Busway at the bus stops and there is no physical prevention for pedestrians to enter the Busway lanes. There is no signage on the Busway, itself stating pedestrians should not enter and only a small sign on a post by the footpath which states pedestrians should not trespass on the Busway. Although the footpaths which run parallel to the Busway are separated by fences, there are a number of places where pedestrians may freely enter the Busway. Hatters Way, Luton has many gaps in the fence, with no gate, giving pedestrians free access to roam in and out of the Busway lanes. There are no signs of bus stops near these gaps in the fences and, at the Bury Park end of Hatters Way, there is no fencing which again means pedestrians are free to enter the Busway lanes. Unlike train tracks, where the only way to get access is via a station, the Busway is easily accessed, yet it is just as dangerous; ”

    Source location

    Ibrahima YAHAIA · Prevention of Future Deaths report
    Page 2 · 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

    Entire-length fencing cannot be installed because it would be prohibitively expensive and is not considered necessary for busway infrastructure.

    Verbatim wording from the response

    “At no stage has LBC or CBC been advised that the Busway should be fenced along its entire length and indeed to do so would be prohibitively expensive. I understand that no busways are fenced in the same way as a railway and the two should not be seen as comparable.”

    Source location

    2020-0262-Response-from-Luton-Council-Redacted
    Page 1 · response
    Published 4 January 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

    Unauthorised access cannot be prevented along the Busway’s full 8.3-mile length.

    Verbatim wording from the response

    “I feel that I must nonetheless point out that it is impossible to prevent unauthorised access to the Busway along its 8.3 mile length of which 4.6 miles is guided.”

    Source location

    2020-0262-Response-from-Luton-Council-Redacted
    Page 3 · response
    Published 4 January 2021

    Open published response
  8. Inner North London

    AI-generated summary

    Martin Edward ELLIS · 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

    Martin Edward Ellis was electrocuted at the Sir John Compton Dam in Saint Lucia while holidaying there with his family. The concerns included inadequate access restriction and warning signage, exposed live wiring in a galvanised metal conduit, and the lack of an explanation or investigation report about the exposed wire six months after his death.

    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 prevent public access to the dam

    Wider context from the report

    “1. The dam is apparently not open to members of the public, but Mr Ellis and his family were able to visit it with ease, not even knowing that it was restricted, still less having access prevented. ”

    Source location

    Martin Edward ELLIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Manchester South

    AI-generated summary

    Peter Geoffrey Francis Harrison · 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 17 December 2018, Peter Geoffrey Francis Harrison was found at the bottom of an external staircase and had multiple injuries, including head injuries. The inquest concluded that the death was suicide; concerns included that the maintenance staircase was accessible from a shopping area and had no lockable gate, despite not requiring regular public access.

    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 controlled access to maintenance-use external staircases

    Wider context from the report

    “1. The external staircase used by Mr Harrison was to the rear of a shopping area. The inquest heard that access could easily be gained to the staircase and there was no gate that could be locked. The staircase was for maintenance use and did not require regular access by the public. ”

    Source location

    Peter Geoffrey Francis Harrison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. Nottinghamshire

    AI-generated summary

    Stanislawa Kmiecik · 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

    Stanislawa Kmiecik entered an inaccessible mezzanine area in a Nottingham store and fell approximately 18 feet through an open space to the basement floor, sustaining multiple injuries and dying at the scene. The concerns identified included public and staff access to the area, lack of warning signage and fall protection, uneven flooring, and the risk of objects falling through the openings onto people below.

    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 prevent access to the mezzanine openings

    Wider context from the report

    “(3) Whilst the area is cordoned off from the main shop floor by way of a locked mesh gate and some scaffolding type posts, it remains possible for staff and/or members of the public to access the area. ”

    Source location

    Stanislawa Kmiecik · 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

    Replace the broken gate lock.

    Verbatim wording from the response

    “• the broken lock was replaced on Monday 15 April 2019 ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 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

    Restrict access beyond the gate to authorised staff and extend the instruction to new staff.

    Verbatim wording from the response

    “• immediately after the incident all moveable items beyond the gate were removed and all members of staff were instructed not to access the area beyond the gate unless authorised to do so. That instruction not to access the area beyond the gate has been repeated and will cover new members of staff ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 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 incident was almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.

    Verbatim wording from the response

    “We do not wish to pre-judge the evidence that will be heard at the inquest. However, it does seem plain that the cause of the incident was almost certainly a deliberate attempt by the deceased to put herself in a position of danger and potentially take her own life. There can be no other credible explanation for the individual unsecuring the gate or climbing over the gate and then going beyond the scaffolding. No member of the public has ever attempted previously to access the area beyond the gate.”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 2019

    Open published response
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Data last updated 7 September 2026