Recurring concern

Unreliable annual safety inspection processes

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First reported 22 Jun 2018•Latest report 24 Jan 2024

Definition

What this concern includes

Includes failures in annual safety inspection processes where responsibility, continuity, inspection scope, format, criteria or decision-making controls are inadequate or unreliable, including the anchor’s unclear accountability and handover arrangements and the Coal Authority’s inadequate inspection content and criteria.

Not included

Excludes inspections that are not annual unless the report explicitly links them to the same annual inspection process.
Excludes routine maintenance, repair or remedial-action failures where the inspection process itself was adequate.
Excludes generic organisational accountability, staffing or record-keeping deficiencies that are not directly tied to annual safety inspections.
Excludes failures in the underlying safety condition or hazard where no deficiency in the annual inspection process is identified.
Excludes regulatory or external inspection failures where the concern is limited to the inspector’s failure to detect a specific defect and does not support the broader annual inspection process.

Reports: 3
Individual concerns: 3
Date range: 2018–2024
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Canal & River Trust1

Coal Authority1

London Borough of Tower Hamlets1

Mining Remediation Authority1

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.

24 Jan2024
South Wales Central
Concerns raised1
1. Inadequate annual safety inspection content, format and decision-making criteria
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Operate the Public Safety Risk Assessment process to classify sites, prioritise visits proportionately and track timely recommendations.
  Stated by Mining Remediation AuthorityStated completed
AI-generated summary

Christopher Kapessa · 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

Christopher Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.

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 annual safety inspection content, format and decision-making criteria
Wider context from the report
“(3) The annual inspections conducted by the Coal Authority were limited in content, unclear in format and identified no clear criteria to be used for the basis of decision making. ”
Source location
Christopher Kapessa · 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
Operate the Public Safety Risk Assessment process to classify sites, prioritise visits proportionately and track timely recommendations.

Verbatim wording from the response
“As outlined in ████████ letter of the 17th January, a new Public Safety Risk Assessment (PSRA) process was introduced during July 2020. The PSRA, its associated guidance and the e-learning package, was developed by the Authority’s Safety, Health & Environment (SHE) team in collaboration with the Environment Agency and with good practice adapted to meet the specific needs of the Authority.”

Source location
Response from Browne Jacobson
Page 5 · response
Published 12 February 2024
Open published response
7 Mar2019
North Wales (East and Central)
Concerns raised1
1. Failure of upright embedment testing to provide accurate and regular assessments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Inspect each aqueduct upright and check its engagement during the forthcoming Principal Inspection, compare results with 2016 findings, and review future checking frequency.
  Stated by Canal & River TrustStated planned
Respondent positions 1
1. Position
  The existing risk-based inspection regime is proportionate and repeatable, with training, checking and peer review ensuring consistency.
  Stated by Canal & River TrustExisting arrangements considered sufficient
AI-generated summary

Kristopher John McDowell · 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 31 May 2016, Kristopher John McDowell fell to his death from the Pontcysyllte aqueduct after an upright rail he was holding became detached while he was on the non-pedestrian side. The concerns identified were that the parapet uprights were spaced widely enough for people to pass through, and that signage did not adequately mitigate this risk. Concerns were also raised that inspection and testing processes were inadequate to ensure the uprights remained properly engaged.

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 of upright embedment testing to provide accurate and regular assessments
Wider context from the report
“(a) The average space between the uprights on the parapet on the aqueduct is 195mm whilst the current industry standard is 110mm as a result of which there exists a risk that a person might be able to pass between them. This is a particular risk for children using the aqueduct but it is also a significant risk for young persons or adults being of sufficient width for them to pass through in circumstances whereby it was their intention to gain access to the non-pedestrian side of the parapet for a purpose which would not be considered the intended use of the structure. In my opinion, the use of signage alone, warning users of the potential risk, does not adequately mitigate the risk of a person passing through the uprights and falling from the aqueduct. (b) Evidence provided by an expert instructed by the Canal and River Trust (CRT) indicated that it was his belief that the upright became detached as a result of a lifting action which dis-engaged the nib on the bottom of the upright from the socket on the outside of the parapet. The evidence provided to the inquest by engineers from CRT advised that their inspection procedures provided for an Annual Inspection which included testing for the extent of embedment by a push/pull/lift test, however in my opinion the subjective elements of this test would permit inconsistencies in the information which it provides. Furthermore, exact measurements of the degree of embedment of uprights would only routinely be established in the course of a Principal Inspection which takes place every twenty years and as a result it is difficult for there to be an accurate/regular assessment of the rates of possible deterioration and hence the true extent of embedment. In my opinion, the testing processes currently adopted (in regard to the matters detailed above) are inadequate to ensure that the uprights are properly engaged at all times. ”
Source location
Kristopher John McDowell · 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
Inspect each aqueduct upright and check its engagement during the forthcoming Principal Inspection, compare results with 2016 findings, and review future checking frequency.

Verbatim wording from the response
“Notwithstanding this, we are not complacent and are very concerned that there should be public confidence in our stewardship of the Aqueduct. During the forthcoming Principal Inspection which will be undertaken this year, the condition of each of the uprights will be inspected and the engagement will be checked again. We will compare this result with the 2016 inspection and consider further what the frequency of future checking needs to be. The inspection and the review will be completed by early 2020.”

Source location
2019-0083-Response-by-Canal-River-Trust
Page 4 · 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 risk-based inspection regime is proportionate and repeatable, with training, checking and peer review ensuring consistency.

Verbatim wording from the response
“Our inspection processes are determined from a risk-based approach that balances likelihood and consequence of a failure, and considers issues such as the material properties of the railing and the known low rates of degradation. The 2016 Special Inspection confirmed that all of the uprights were sufficiently engaged.”

Source location
2019-0083-Response-by-Canal-River-Trust
Page 4 · response
Published 9 June 2019
Open published response
22 Jun2018
Inner North London
Concerns raised1
1. Lack of clear accountability and continuity for annual inspections
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Alexia Awenimi WALENKAKI · 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

Alexia Awenimi Walenkaki died after falling from a rope suspended from a wooden post that collapsed while she was playing in a children’s play area on 17 July 2015. The jury identified the use of inappropriate wood and organisational failure, including a lack of accountability for annual inspections, as causative factors. The coroner was concerned that unclear responsibility and continuity in management structures could lead to recurrence.

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 clear accountability and continuity for annual inspections
Wider context from the report
“The jury identified two causative factors in the equipment failure that resulted in Alexia’s death: - inadvertent use of inappropriate wood; - organisational failure and lack of accountability for annual inspections. When one person was suspended and another went on maternity leave, there was no clear handover of responsibility for annual inspections. I fear that a lack clarity and continuity in terms of role demarcation and management structure may persist, particularly when staff move on. Whilst I heard that there have been changes at Tower Hamlets since Alexia’s death, I am concerned that there is the potential for recurrence of the organisational failure identified by the jury. ”
Source location
Alexia Awenimi WALENKAKI · 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 annual safety inspection content, format and decision-making criteria

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

Concerns raised1

Failure of upright embedment testing to provide accurate and regular assessments

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clear accountability and continuity for annual inspections

Actions described in response 1

Actions described in response 1

Respondent positions 1