16 Oct 2025 Theo Treharne-Jones · Prevention of Future Deaths report South Wales Central
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Concerns raised 5 Failure to provide parents with information about hotel room door security View source Hotel room door locks failing to prevent unsupervised exit View source Lack of secondary hotel room door security measures View source Lack of a physical barrier preventing unsupervised child access to the pool View source Failure of ABTA guidance to address hotel room exit security View source See 2 more concerns
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AI-generated summary
Theo Treharne-Jones · 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
Theo Treharne-Jones, aged 5, died by drowning in a swimming pool at a holiday village in Kos, Greece, after leaving his hotel room unnoticed while his parents were asleep. The hotel room locks did not prevent him from leaving, there was no secondary security measure, and the pool had no physical barrier to prevent uncontrolled or unsupervised access by children. Theo was unable to swim and had developmental delay and no sense of danger.
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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. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide parents with information about hotel room door security
Wider context from the report “No specific information about door locks and security chains was given to Theo’s parents on booking or on arrival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Hotel room door locks failing to prevent unsupervised exit
Wider context from the report “The door locks in the hotel room were of a design to promote safety during a fire and could be easily disengaged from the inside ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of secondary hotel room door security measures
Wider context from the report “There was no secondary security measure such as a chain in place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of a physical barrier preventing unsupervised child access to the pool
Wider context from the report “The pool that Theo was found in did not have any physical barrier in place to prevent uncontrolled or unsupervised access by children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of ABTA guidance to address hotel room exit security
Wider context from the report “ABTA guidance does make reference to a security chain/latch but this is the context of enabling customers to identify a visitor at the door and merely states such could be provided. However, there is no reference in the guidance to any form of security in the sense of controlling the exit from the room .
” Open source report
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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 Produce and maintain multilingual tourism accommodation health and safety guidance covering room security and emergency escape requirements.
Verbatim wording from the response “As part of our ongoing commitment to support improvement within the tourism accommodation sector, through collaboration with our members and a team of health, safety and security specialists, ABTA has produced a guidance publication called the ABTA tourism accommodation health & safety technical guide.” Source location Response from ABTA
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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 Security chains beyond the stated purpose could create fire safety risks and hinder emergency evacuation.
Verbatim wording from the response “We have considered your recommendation and in our view the recommendation of security chains for any other reason than highlighted above could inadvertently create fire safety risks and hamper customer evacuation in an emergency.” Source location Response from ABTA
Open published response
9 Oct 2023 Sandra Curran · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Lack of warnings about local sea conditions, swimming risks and risk mitigation for weak swimmers View source
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
Sandra Curran · 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
Sandra Curran died after becoming unresponsive while snorkelling in the sea off Bugibba Saint Paul's, Malta, on 4 July 2022; an investigation found that she died from asphyxia as a consequence of drowning. The principal concern was that UK tour operator welcome information did not warn about the risks and challenges of sea swimming or snorkelling in Malta, particularly for weak swimmers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about local sea conditions, swimming risks and risk mitigation for weak swimmers
Wider context from the report “The inquest heard the Mrs Curran had booked her holiday through a UK Tour operator. Mrs Curran was not a strong swimmer and that she was unaware of the risks that swimming/snorkelling in the sea off the coast of Malta could present. No warnings were given in the welcome information/briefing about the challenge the sea around the coast in Malta could present to a weak swimmer. Previously when she had snorkelled it had been in far easier conditions where the risks of strong currents had not been present. The evidence given by her family at the inquest was that had her tour operator highlighted the need for caution Mrs Curran would not have snorkelled alone in the area where she drowned. A more proactive approach by UK tour operators highlighting the risk of getting into difficulties and how to mitigate them would reduce the risk of further deaths in circumstances such as Mrs Curran’s.
” Open source report
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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 disseminating swim-safety guidance through ABTA websites, social-media campaigns, and member and stakeholder channels.
Verbatim wording from the response “ABTA runs a number of consumer campaigns where evidence from our members has highlighted that increased awareness on particular issues is important. We have been raising the importance of swim safety to consumers for over 20 years, and have been running a dedicated campaign on swim safety for around 10 years.” Source location Response from ABTA
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7 Jul 2017 Christopher Bell and 29 others · Prevention of Future Deaths report London (West)
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Concerns raised 2 Lack of board-level security advisors in travel companies View source Failure by holiday and travel sellers to prominently display Travel Aware information and links View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher Bell and 29 others · 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
Thirty British nationals were killed in a terrorist attack at the Imperial Mahaba Hotel in Sousse, Tunisia, on the morning of 26 June 2015. The concerns identified were whether travel companies had board-level security expertise and whether holiday and travel websites provided sufficiently prominent information about terrorist risks through the Government’s Travel Aware programme.
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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. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of board-level security advisors in travel companies
Wider context from the report “(1) I heard evidence that prior to the attack neither TUI nor other travel companies had security advisors on their boards . The evidence of a TUI witness was that “security was a matter for the accommodation hoteliers and providers”. I am informed that TUI now have such an advisor. However I remain concerned that if other companies do not have similar security advisors at board level then hotels which they use will not be adequately protected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure by holiday and travel sellers to prominently display Travel Aware information and links
Wider context from the report “(2) I heard evidence that prior to the attack, TUI's websites for Thomson and First Choice did not prominently display logos and links to the Government’s Travel Aware programme , which provides detailed travel advice for every country on the Foreign and Commonwealth Office website. I heard evidence that TUI have taken steps to change their website and promote literature to make these logos and links more prominent. I remain concerned that other companies which sell holidays, or sell flights and hotel accommodation separately, may not have taken such steps , as a result of which members of the public receive insufficient information about the risks of terrorist attacks in destination countries .
” Open source report
25 Jul 2016 Alfie Wayne Eddie Gray · Prevention of Future Deaths report West Sussex
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Concerns raised 5 Failure of lifeguard communication with holiday makers during emergencies View source Inadequate lifeguard staffing levels View source Failure to communicate lifeguard absence information to families View source Failure to maintain continuous lifeguard coverage View source Lack of medical training for lifeguards View source See 2 more concerns
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
Alfie Wayne Eddie Gray · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Wayne Eddie Gray, aged 7, drowned in a hotel resort pool in Sharm El Sheikh, Egypt, on 7 July 2015 after he went missing while playing in the pool. Concerns were raised that lifeguard provision was inadequate, lifeguards lacked medical training, communication was difficult, and lifeguards were off duty during lunchtime without this being communicated to the family.
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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. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of lifeguard communication with holiday makers during emergencies
Wider context from the report “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate. The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate lifeguard staffing levels
Wider context from the report “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate . The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate lifeguard absence information to families
Wider context from the report “(2) The lifeguards went off duty for an hour over lunchtime. This information was not communicated to the family either by the hotel or the travel company .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous lifeguard coverage
Wider context from the report “(2) The lifeguards went off duty for an hour over lunchtime . This information was not communicated to the family either by the hotel or the travel company.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of medical training for lifeguards
Wider context from the report “(1) The provision of lifeguards. It appeared that the number of lifeguards on duty at this resort were inadequate. The life guards did not have any medical training and communication with the holiday makers proved difficult when help was needed.
” Open source report
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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 promoting member guidance that accommodation staff receive lifesaving, CPR and first-aid training.
Verbatim wording from the response “The Technical Guide section on Pool Safety addresses emergency procedures from management responsibility to appropriate staff training. The Management Responsibility section addresses the need to train staff in lifesaving techniques, CPR and first aid. We believe that this reflects current best practice and we continue to promote this approach for Members to their suppliers.” Source location 2016-0262-Response-by-ABTA
Open published response
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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 Technical Guide reflects current best practice on lifeguards and customer information where no international lifeguard standard exists.
Verbatim wording from the response “The presence of lifeguards at swimming pools is not a legal requirement in many overseas countries, nor is it in the UK. The current Technical Guide section on Pool Safety and Waterparks addresses the subject of lifeguards. In the Customer Information section there are clear recommendations on the need to inform customers as to whether there is a lifeguard present or not.” Source location 2016-0262-Response-by-ABTA
Open published response
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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 Technical Guide’s emergency procedures and staff training requirements reflect current best practice for lifesaving techniques, CPR and first aid.
Verbatim wording from the response “The Technical Guide section on Pool Safety addresses emergency procedures from management responsibility to appropriate staff training. The Management Responsibility section addresses the need to train staff in lifesaving techniques, CPR and first aid. We believe that this reflects current best practice and we continue to promote this approach for Members to their suppliers.” Source location 2016-0262-Response-by-ABTA
Open published response
18 Sep 2015 Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 10 Failure of Tour Operators to collaborate and share health and safety information View source Failure to provide carbon monoxide detectors in accommodation with individual gas appliances View source Lack of a central register and up-to-date energy-source and service-history information for holiday premises View source Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises View source Delegation of health and safety checks to inexperienced and overworked Tour Representatives View source Failure to provide clear traveller information about carbon monoxide dangers and safeguards View source Lack of robust internal health and safety management, supervision, support and training View source Lack of publicly accessible accommodation health and safety inspection reports View source Lack of suitably qualified specialist health and safety inspections at holiday accommodation View source Failure to carry out annual accommodation safety audits View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christianne Shepherd and Robert Shepherd · 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
Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.
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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. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of Tour Operators to collaborate and share health and safety information
Wider context from the report “2. In most situations a hotel, apartment or other holiday premises will be used by more than one Tour Operator. In this event a system should be devised for Tour Operators to work in collaboration with communicate and actively share information pertaining to Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carbon monoxide detectors in accommodation with individual gas appliances
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises.
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation , which has individual gas appliances , whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of a central register and up-to-date energy-source and service-history information for holiday premises
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises .
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Delegation of health and safety checks to inexperienced and overworked Tour Representatives
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task . The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear traveller information about carbon monoxide dangers and safeguards
Wider context from the report “7. All holiday brochures and travel promotional literate and Health and Safety information should be written in clear, easy to understand language and should make specific reference to the dangers of carbon monoxide poisoning , and make reference to safeguards that travellers should adopt .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of robust internal health and safety management, supervision, support and training
Wider context from the report “6. Within the structure and hierarchy of every provider of hotels, apartments and holiday premises there should be a robust internal structure for a system of management, supervision support and training in respect of Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly accessible accommodation health and safety inspection reports
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible . In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of suitably qualified specialist health and safety inspections at holiday accommodation
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety . Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks , the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out annual accommodation safety audits
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period .
” Open source report
Concerns raised 5 Lack of best-practice requirements for first-aid-trained swimming-pool lifeguards View source Lack of emergency equipment at hotels and resorts View source Lack of best-practice requirements for resuscitation equipment at swimming pools View source Lack of best-practice requirements for emergency procedures at hotels and resorts View source Lack of best-practice requirements for rescue equipment at swimming pools View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Loui Aspinall · 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
Loui Aspinall died after walking into a swimming pool at a hotel resort in Tunisia and becoming submerged. The concerns included the apparent absence of obvious resuscitation and rescue equipment, uncertainty about lifeguard provision and first-aid training, and gaps in tour-operator best-practice guidance on pool safety and emergency procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice requirements for first-aid-trained swimming-pool lifeguards
Wider context from the report “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency equipment at hotels and resorts
Wider context from the report “iii. The best practice guidelines issued by the Federation of British Tour Operators do not refer to emergency procedures at hotels and resorts. The availability of emergency procedures and emergency equipment at hotels and resorts are necessary to reduce a risk that future deaths will occur unless action is taken
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice requirements for resuscitation equipment at swimming pools
Wider context from the report “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice requirements for emergency procedures at hotels and resorts
Wider context from the report “iii. The best practice guidelines issued by the Federation of British Tour Operators do not refer to emergency procedures at hotels and resorts . The availability of emergency procedures and emergency equipment at hotels and resorts are necessary to reduce a risk that future deaths will occur unless action is taken
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice requirements for rescue equipment at swimming pools
Wider context from the report “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool .
” Open source report
Concerns raised 5 Failure to use available urgent medical services and communications View source Failure to recognise the severity and subtle signs of mountain sickness View source Failure to limit high-altitude ascents to safe rates View source Failure to ensure and verify guide training in acute mountain sickness View source Failure to provide passive descent or health-centre treatment for severe altitude illness View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rachel Ann Burke · 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
Rachel Ann Burke died in Dole, Nepal, after developing high altitude cerebral oedema and high altitude pulmonary oedema during a Himalayan trek. Concerns included an excessive rate of ascent, failure to use a nearby health post or satellite phone for urgent care, failure to recognise the severity of her illness, and sending her to descend under her own steam with a guide who had inadequate or no training in acute mountain sickness.
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. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to use available urgent medical services and communications
Wider context from the report “(2) The HE trek leader was concerned about the costs of accessing services from the Health Centre and of making satellite phone calls , possibly mindful of the TAC manual for overseas group leaders, which states under “emergency” on page 20, that priority must be given to finding a cost effective solution. Despite having a satellite phone at Macheremo and 12 minutes from a health post, neither was used, when the trekker needed urgent medical care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the severity and subtle signs of mountain sickness
Wider context from the report “(3) The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness. This should not happen, the expert said, since exercise worsens HAPE. Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and guide was not passed to TAC, who assured themselves of the adequacy of training by statements of general compliance from HE. Whilst the companies report that action has been taken to address this, there may remain a similar risk for other trek organizers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to limit high-altitude ascents to safe rates
Wider context from the report “(1) The Adventure Company (TAC) Everest Gokyo Lakes Trek had advertised the ascent from Namche Bazaar at 3440m to Dole at 3780m, when in fact it was 4050m. This was an ascent of 610m in one day, whilst its preferred code of practice identified that ascents should be of a maximum of 300m per day. An expert in mountain sickness, ████████ said that the speed of ascent was the one factor that limits the incidence of altitude sickness. He said that the sleeping altitude (above 3000 metres) should never be more than about 300 or 400 metres above the previous night and that every 3 days or 1000 metres of additional ascent, an additional rest day would be needed. He described the ascent to Dole on this trek as excessive, being double the safe recommended ascent rate. It was noted that TAC hold a high altitude trek in Peru where the limits are strictly complied with, due to local legislation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure and verify guide training in acute mountain sickness
Wider context from the report “(3) The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness. This should not happen, the expert said, since exercise worsens HAPE. Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and guide was not passed to TAC, who assured themselves of the adequacy of training by statements of general compliance from HE. Whilst the companies report that action has been taken to address this, there may remain a similar risk for other trek organizers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ABTA Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide passive descent or health-centre treatment for severe altitude illness
Wider context from the report “(3) The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness. This should not happen, the expert said, since exercise worsens HAPE. Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and guide was not passed to TAC, who assured themselves of the adequacy of training by statements of general compliance from HE. Whilst the companies report that action has been taken to address this, there may remain a similar risk for other trek organizers.
” Open source report
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Addressed to Federation of Tour Operators, now represented here by ABTA Ltd.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations