10 Apr 2025 Mr Joel Kenneth Ineson · Prevention of Future Deaths report Sunderland
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Concerns raised 6
Lack of emergency plans for organised open water swimming events View source Unclear responsibility for safety measures at organised open water swimming events View source Lack of specific health and safety guidance and compliance requirements for event risk assessments View source
Lack of regulatory licensing and oversight for organised open water swimming events View source Lack of training requirements for open water swimming event organisers View source Failure to provide specific pre-session safety briefings View source See 3 more concerns
This report raised 2 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.
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AI-generated summary
Mr Joel Kenneth Ineson · 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
Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.
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× 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 emergency plans for organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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 Unclear responsibility for safety measures at organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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 specific health and safety guidance and compliance requirements for event risk assessments
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance , nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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 regulatory licensing and oversight for organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation .
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity . It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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 training requirements for open water swimming event organisers
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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 specific pre-session safety briefings
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing , a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing , risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Source location Mr Joel Kenneth Ineson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting and liaising with local-authority regulatory partners on enforcement of work-related health and safety legislation.
Verbatim wording from the response “HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulations and guidance provide a suitable basis for safe public open water swimming, so HSE will not publish specific guidance.
Verbatim wording from the response “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforcement responsibility lies with HSE or the relevant local authority, with local authorities predominantly enforcing work-related health and safety legislation in this area.
Verbatim wording from the response “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An AALA licence is not relevant because the licensing scheme concerns specified tuition for children, not adult swimming events.
Verbatim wording from the response “The Adventure Activities Licensing Regulations 2004 have a very specific purpose and were never intended to apply to all adventure activities or adult adventure activities. The Adventure Activities Licensing Authority (AALA) licence is aimed at those who provide tuition in specified adventure activities to children, and therefore it was not relevant to a swimming event for adults.” Source location Response from Health and Safety Executive
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20 Dec 2024 David John Haw · Prevention of Future Deaths report Dorset
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Concerns raised 2
Lack of specific guidance on support-boat responsibilities at sailing events View source Failure of vessel owners and operators to know support-boat use and passenger identity View source
This report raised 6 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.
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AI-generated summary
David John Haw · 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
David John Haw was thrown from a support RHIB after it collided with a buoy in Poole Harbour at approximately 30 knots on 2 May 2022. He was recovered from the water on 14 May 2022, and the inquest recorded drowning and concluded unlawful killing. The concerns include differing safety requirements for pleasure and commercial vessels, alcohol use by pleasure-vessel helms, the absence of requirements for lifejackets on some vessels, and the use and regulation of support boats at sailing events.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific guidance on support-boat responsibilities at sailing events
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware, as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats . I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events , which could lead to a future death.
” Source location David John Haw · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of vessel owners and operators to know support-boat use and passenger identity
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware , as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats. I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events, which could lead to a future death.
” Source location David John Haw · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage Organising Authorities to use safety management systems and implement event-specific measures to manage identified risks.
Verbatim wording from the response “While the RYA does not believe it appropriate for an Organising Authority to be required to influence the behaviour of boats in the vicinity of an event, such as boats unconnected with the event or boats used after hours or after the event has finished, the RYA is actively encouraging all Organising Authorities to have safety management systems in place for their activities. A safety management system should include consideration of applicable risks and detail the steps taken to minimise the risks identified. This will vary by event; however, the RYA is aware that some Organising Authorities of events in coastal areas have already considered laying on water taxis between venues or to return crews to competing yachts and therefore reduce the need for private boats to be used for transferring people.” Source location Response from Royal Yachting Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The respondent cannot mandate particular support-boat provisions because each organising authority determines its event requirements.
Verbatim wording from the response “The Racing Rules of Sailing (as set by World Sailing) provide that an Organising Authority should issue a Notice of Race and go on to detail what an Event Organiser should include in that Notice of Race. Accordingly, it is for each Organising Authority to determine what is appropriate for its own event, and the RYA is unable to mandate particular provisions.” Source location Response from Royal Yachting Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational standards for recreational and small commercial vessels are outside the respondent’s authority.
Verbatim wording from the response “Whilst the RYA has the authority to determine the standards for its courses and for the conditions under which RYA recognised training centres operate, it does not have the authority to determine or enforce standards for operations within either the recreational sector or small commercial vessel sector. This responsibility falls to the MCA as the UK maritime regulator, and to local harbour authorities who have certain powers within their respective jurisdiction.” Source location Response from Royal Yachting Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MCA and relevant harbour authorities are responsible for regulating recreational and small commercial vessel operations.
Verbatim wording from the response “Whilst the RYA has the authority to determine the standards for its courses and for the conditions under which RYA recognised training centres operate, it does not have the authority to determine or enforce standards for operations within either the recreational sector or small commercial vessel sector. This responsibility falls to the MCA as the UK maritime regulator, and to local harbour authorities who have certain powers within their respective jurisdiction.” Source location Response from Royal Yachting Association
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Includes failures in safety arrangements specifically for organised water-sports events, including responsibility allocation, participant and vessel safety guidance, safety briefings, event risk planning, participant accountability and emergency arrangements where these directly support safe operation of the event.
