26 Feb 2026 William Anthony Elvis WEBB · Prevention of Future Deaths report Cheshire
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Concerns raised 2 Lack of nearby signage alerting people to the potential risks of the canal View source Lack of means for people to get out of the canal unaided View source
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AI-generated summary
William Anthony Elvis WEBB · 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
William Webb was reported missing after failing to return home and was later found deceased in the Shropshire Union canal on 24 November 2025. CCTV indicated that he likely accidentally fell into the canal on 23 November and died by drowning after being unable to self-rescue. The report raised concerns about the absence of safety equipment and nearby warning signage, and the difficulty of getting out because of the distance between the water and the ground edge.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nearby signage alerting people to the potential risks of the canal
Wider context from the report “The area in which Mr Webb fell into the canal is close to student accommodation. Whilst this is a generalisation and is by no means all students, students as a group are within the demographic of people who will attend the bars, pubs and nightclubs of Chester and become inebriated to varying degrees. Once under the influence of alcohol, or perhaps another substance, it is then not inconceivable that they then take less care/ are more willing to engage in risky behaviours. The canal is near to their accommodation, which makes it more likely that they will be in that area. Once in the water, there is currently no safety equipment which could assist someone in getting out, whether they are in accidentally or intentionally, and the distance between the water level and the ground edge (the freeboard), is, in my view, such that it would be difficult to get out without assistance. There is also no signage nearby which alerts people to the potential risks . I heard varying evidence as to the depth of the water, with the police describing it as around 5ft, and the Canal and River Trust indicating it was around 1 metre.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of means for people to get out of the canal unaided
Wider context from the report “The area in which Mr Webb fell into the canal is close to student accommodation. Whilst this is a generalisation and is by no means all students, students as a group are within the demographic of people who will attend the bars, pubs and nightclubs of Chester and become inebriated to varying degrees. Once under the influence of alcohol, or perhaps another substance, it is then not inconceivable that they then take less care/ are more willing to engage in risky behaviours. The canal is near to their accommodation, which makes it more likely that they will be in that area. Once in the water, there is currently no safety equipment which could assist someone in getting out, whether they are in accidentally or intentionally , and the distance between the water level and the ground edge (the freeboard), is, in my view, such that it would be difficult to get out without assistance . There is also no signage nearby which alerts people to the potential risks. I heard varying evidence as to the depth of the water, with the police describing it as around 5ft, and the Canal and River Trust indicating it was around 1 metre.
” 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 Coordinate with the Water Safety Partnership and relevant landowners to identify and discuss potential additional water-safety mitigation measures.
Verbatim wording from the response “• Consequently and to address the specific risks presented by the public realm over which the Trust has no control, I have, on behalf of the Trust, requested the WSP’s support in writing to relevant riparian owners of the land surrounding the Shropshire and Union Canal, inviting them to a meeting to discuss what further steps can be taken collectively, or on an individual basis to provide additional mitigation of water safety risks in this area. Layout of the public realm, signage, lighting and the provision of Personal Rescue Equipment are to be raised, the necessity and benefit of which will be considered alongside issues such as the depth of the water and the height of the freeboard. We will work proactively with the WSP and the relevant landowners to identify where such measures may be implemented/improved and provide advice and assistance where we are able to do so.” Source location Response from Canal & River Trust
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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 Direct action on public-realm water safety risks is limited because the surrounding land is not owned or controlled by the respondent.
Verbatim wording from the response “As indicated in the Trust’s initial response (dated 3rd of February 2026) to your questions preceding the Inquest, the land surrounding the Shropshire Union Canal in the vicinity of the University accommodation, and crucially where Mr Webb entered the water, is not owned by the Trust. This presents a number of challenges and limits the actions we are able to take directly. Notwithstanding and following the Inquest and the concerns raised in the Regulation 28 Report (dated 26th February 2026), the Trust has taken the following actions:” Source location Response from Canal & River Trust
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14 Mar 2022 Mrs. Margaret May Lewis · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Risk of pedestrian collisions when crossing the B4398 View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs. Margaret May Lewis · 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
Mrs. Margaret May Lewis was fatally injured on 6 November 2020 when she was struck by a car while crossing the B4398 to re-join the Montgomeryshire Canal towpath. The report identifies concerns about the risk of similar accidents because the road has a 60 mph speed limit, electric cars may be difficult to hear, and pedestrians exercising may wear earphones.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of pedestrian collisions when crossing the B4398
Wider context from the report “The Montgomeryshire canal and its adjacent towpath is a popular venue for adults with children and dogs; and joggers many of whom will wear earphones. They, like Mrs. Lewis who was thought to be wearing earphones at the time, will need to cross the B4398 (which has a 60 mph speed limit) to continue their exercise.
With the increasing popularity of noiseless electric cars, the frequency of wearing earphones whilst taking exercise and the B4398 having a 60mph speed limit, I consider there is a risk of reoccurrence of such an accident.
Within the Highway Code for pedestrians it states “Keep looking and listening for traffic while you cross, in case there is any traffic you did not see, or in case other traffic appears suddenly. Do not walk diagonally across the road.”
” 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 Procure and install bilingual warning signs at the B4398 kissing gates and 40 similar gates across the Welsh and English sections of the Montgomery Canal.
Verbatim wording from the response “Currently, there is no highways signage on the ‘Kissing Gates’ as we are not responsible for risk control measures for the Highway itself and the barrier that the gate provides, slows and stops the user at the end of our towpath. However, at your request, we have designed warning signage to be placed on front and rear of the ‘kissing’ gates either side of the B4398 which will read as follows:” Source location Response from Canal & River Trust
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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 Highway risk-control measures, including signage on the B4398, are outside the Trust’s responsibility.
Verbatim wording from the response “Currently, there is no highways signage on the ‘Kissing Gates’ as we are not responsible for risk control measures for the Highway itself and the barrier that the gate provides, slows and stops the user at the end of our towpath. However, at your request, we have designed warning signage to be placed on front and rear of the ‘kissing’ gates either side of the B4398 which will read as follows:” Source location Response from Canal & River Trust
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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 Existing kissing gates adequately slow and stop towpath users before they cross the road.
Verbatim wording from the response “The Montgomery Canal towpath is moderately used by local people and sees pedestrians and some cyclists. The towpath does have many sections where the towpath stops at a road and then restarts on the other side of the road. In order to ensure that any user of the canal prepares for crossing there is a barrier in the form of a kissing gate as per photograph below.” Source location Response from Canal & River Trust
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9 Mar 2022 Tomi Obi Solomon · Prevention of Future Deaths report West Yorkshire, Western
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Concerns raised 1 Failure of safety measures on the bridge and surrounding area to deter such activities 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
Tomi Obi Solomon · 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 1 June 2021, 13-year-old Tomi Obi Solomon voluntarily jumped from a bridge into the river and drowned after struggling to swim. The report raises concerns about the adequacy of safety measures at the bridge and surrounding area, given its popularity with teenagers for swimming and jumping into the water.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of safety measures on the bridge and surrounding area to deter such activities
Wider context from the report “Given the locations popularity with many teenagers in the area, I would ask you to consider the appropriateness of the existing safety measures on the bridge and surrounding area and whether you consider actions are necessary to deter such activities in order to prevent further occurrences and like tragedies.
” Open source report
30 Apr 2021 Eliot Peter Burton · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Lack of on-site supervision at a remote site View source Insufficient prevention of access to the site via the adjacent weir View source Failure to protect deep water channels from falls View source Trespassing by young people onto the site View source Failure to take effective action to reduce the risk of harm from child trespass View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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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.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site supervision at a remote site
Wider context from the report “1. The site is always unmanned . It is located in a remote area
” 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 Canal & River Trust; that does not assign responsibility.
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 .
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to protect deep water channels from falls
Wider context from the report “3. There are deep uncovered channels on the site to conduct water through the facility . It is foreseeable that a trespasser would be in a precarious situation if they were to fall into the water, as Elliot Burton did. Many of the channels are uncovered, and /or have no edge protection .
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Trespassing by young people onto the site
Wider context from the report “2. It is known that in the years 2018-2021, young people have trespassed onto the site .
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take effective action to reduce the risk of harm from child trespass
Wider context from the report “5. Despite the passage of some 21 months since Elliot Burton’s death, little effective action has been taken to reduce the risk of children being harmed if they are tempted to trespass on this site .
” 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 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
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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 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
Open published response
Concerns raised 2 Excessive spacing between aqueduct parapet uprights View source Failure of upright embedment testing to provide accurate and regular assessments 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
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.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive spacing between aqueduct parapet uprights
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.
” 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 Canal & River Trust; that does not assign responsibility.
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.
” 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 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
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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 Investigate physical options for reducing gaps between the aqueduct uprights with relevant partners and regulatory bodies.
Verbatim wording from the response “The Trust has also given further careful thought to this issue raised in your report. It also bears in mind, and has high regard to, the perception by the public of the safety of its structures. Our ambitions and those of our partners for the World Heritage Site are to see it protected and celebrated, drawing increasing numbers of visitors. The significant heritage status of the Aqueduct, including the parapet, means that the Trust must seek explicit consent from the Welsh Government through CADW (the Welsh Government's historic environment service) before carrying out any works to the structure with any permanent changes to the appearance of the Aqueduct likely to be of particular concern. As visitor safety – and perception of safety - remains our paramount concern, we have decided to explore with CADW and our other partners how the” Source location 2019-0083-Response-by-Canal-River-Trust
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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 Develop and submit a final design for reducing the gaps between the uprights for statutory approval after consultation.
Verbatim wording from the response “• For example, at Marple Aqueduct which was referred to at the Inquest, we undertook an informal public consultation relating to the options which guided the final design and, we believe, eased the consenting process. We will expect to do the same here and need to allow sufficient time for this; our outline plan is for this consultation to be conducted later in 2019 and completed by early 2020;” Source location 2019-0083-Response-by-Canal-River-Trust
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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 Conduct an informal public consultation on suitable options for reducing the gaps between the uprights.
Verbatim wording from the response “• We have started an investigation of the physical options available to address gaps between the uprights, working with relevant partners and regulatory bodies. We aim to have this completed by the end of September 2019. If we conclude there is more than one physical option that is suitable (taking into account the physical integrity of the Aqueduct) to reduce the width of the gaps then we will proceed to the consultation process referred to immediately below this bullet point;” Source location 2019-0083-Response-by-Canal-River-Trust
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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 signage, volunteer ranger and information controls adequately address risks associated with normal aqueduct use.
Verbatim wording from the response “Given the Aqueduct’s extraordinary heritage significance, the Trust has deliberately sought to manage the risk of anyone passing between the gaps by non-invasive controls to minimise any impact on the original aqueduct design. As stated in evidence to the Inquest, the Trust uses warning signage to advise visitors prior to them accessing the structure, and through the use of volunteer rangers at peak times and by appropriate information found on the Trust’s website. The signage is installed in prominent locations on the approach to the parapet and on “repeater” posts installed in the towpath. The Trust has identified the risk of unsupervised young children in relation to the gaps, and specifically addresses this in the warning signage. During the course of your investigation, these signs were enhanced by the Trust to advise dog owners that dogs should be kept on a lead.” Source location 2019-0083-Response-by-Canal-River-Trust
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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 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
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20 Nov 2017 Terence DAVIES · Prevention of Future Deaths report Avon
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Concerns raised 1 Extant dangerous informal pathway used by pedestrians and cyclists to access or egress the tow path 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
Terence DAVIES · 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
Terence DAVIES fell from his mobility scooter while travelling along a canal path, suffered a head injury and later died in hospital. The report identified an extant dangerous informal pathway used by pedestrians and cyclists to access or leave the tow path, potentially placing users in 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Extant dangerous informal pathway used by pedestrians and cyclists to access or egress the tow path
Wider context from the report “The dangerous “informal” pathway seen in attached photo and plan is extant. It is used by pedestrians and cyclists alike who may be in danger by using it to access or egress the tow path
” Open source report
23 Nov 2016 Flavio Rafael Pizarro · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Lack of warning signage at locks in the immediate vicinity View source Lack of safety aids at Lock 62 and within the nearby vicinity 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
Flavio Rafael Pizarro · 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
Flavio Rafael Pizarro died after entering the canal at Lock 62 and experiencing difficulties because he was unable to swim. The report identified a lack of warning signs about the dangers of swimming and safety aids at the lock and nearby locks as a concern.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signage at locks in the immediate vicinity
Wider context from the report “There was no signage warning of the dangers of swimming or safety aids at Lock 62 or within the nearby vicinity. There remains no signage at all locks in the immediate area and children continue to play in and near the water despite correspondence dated 5 July 2016 from the Canal % River Trust that stated that signs would be erected at all locks in the immediate vicinity. Future deaths could be prevented by the presence of signs and safety aids.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of safety aids at Lock 62 and within the nearby vicinity
Wider context from the report “There was no signage warning of the dangers of swimming or safety aids at Lock 62 or within the nearby vicinity. There remains no signage at all locks in the immediate area and children continue to play in and near the water despite correspondence dated 5 July 2016 from the Canal % River Trust that stated that signs would be erected at all locks in the immediate vicinity. Future deaths could be prevented by the presence of signs and safety aids.
” Open source report
Concerns raised 3 Lack of means of escape from the canal for people who fall in View source Allowing smokers to smoke outside the hotel near the canal View source Lack of rails or other effective barriers segregating drinkers from the canal 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
Adam Ben Miles · 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
Adam Ben Miles attended a Christmas party at the Hilton Hotel in Sheffield on 12 December 2015 and drowned after falling into the canal basin. The concerns included smoking being permitted near the canal, the lack of effective barriers separating people from the canal, and the absence of means of escape for anyone who fell in.
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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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of means of escape from the canal for people who fall in
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That smokers were allowed to smoke outside the hotel near the canal.
(2) That there wasn't any rails or other effective barriers to segregate drinkers from the dangers of the canal
(3) That the canal didn't have any means of escape for anyone who fell in.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Allowing smokers to smoke outside the hotel near the canal
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That smokers were allowed to smoke outside the hotel near the canal.
(2) That there wasn't any rails or other effective barriers to segregate drinkers from the dangers of the canal
(3) That the canal didn't have any means of escape for anyone who fell in.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of rails or other effective barriers segregating drinkers from the canal
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That smokers were allowed to smoke outside the hotel near the canal.
(2) That there wasn't any rails or other effective barriers to segregate drinkers from the dangers of the canal
(3) That the canal didn't have any means of escape for anyone who fell in.
” 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 Complete a site safety review and risk assessment covering segregation, rescue equipment, self-rescue, lighting and signage at Victoria Quays.
Verbatim wording from the response “On the 3rd May 2016 one of the Trust’s safety advisors visited Victoria Quays and it’s immediate surroundings. Together, he and I have reviewed the matters of concern outlined above and conducted a risk assessment. During the risk assessment we applied the Trust’s guidance on the appropriateness of segregation of the public from the canal basin, rescue equipment (such as a life rings and escape ladders), and the ability of a person to ‘self-rescue’. We came to the following conclusions:” Source location 2016-0132-Response-by-Canal-and-River-Trust
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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 Install two additional life rings on the basin side nearest the hotel.
Verbatim wording from the response “• Means of escape for anyone who fell in. At the time of the incident, there were (and still are) two escape ladders provided in the basin, leading from the water. The ladders were positioned so that they will not be obstructed by the boats mooring in the basin. Importantly, the ‘freeboard’ edges of the basin are also maintained at a height of approximately 400mm from the level of the water itself to allow ‘self-rescue’ in circumstances where a person who falls into the water is capable of staying afloat. Life rings are also located at intervals around the basin for persons who need assistance to float, in accordance with national guidance. However, we have reviewed the number and positioning of the existing life rings and propose to place two additional life rings on the side of the basin closest to the hotel, purely as an additional precautionary measure.” Source location 2016-0132-Response-by-Canal-and-River-Trust
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 Existing escape ladders, basin edges and life rings provide adequate means for self-rescue or assistance to people who fall into the water.
Verbatim wording from the response “• Means of escape for anyone who fell in. At the time of the incident, there were (and still are) two escape ladders provided in the basin, leading from the water. The ladders were positioned so that they will not be obstructed by the boats mooring in the basin. Importantly, the ‘freeboard’ edges of the basin are also maintained at a height of approximately 400mm from the level of the water itself to allow ‘self-rescue’ in circumstances where a person who falls into the water is capable of staying afloat. Life rings are also located at intervals around the basin for persons who need assistance to float, in accordance with national guidance. However, we have reviewed the number and positioning of the existing life rings and propose to place two additional life rings on the side of the basin closest to the hotel, purely as an additional precautionary measure.” Source location 2016-0132-Response-by-Canal-and-River-Trust
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 Existing barriers adequately exclude people from the waterway edge, and the basin’s lighting is considered sufficient for its intended operational use.
Verbatim wording from the response “• Effectiveness of barriers. The level of segregation at Victoria Quays necessarily varies because this is dependant on the activity in the different sections of the canal basin and the land immediately adjacent to the canal. We have reviewed this situation and believe it is appropriate for the intended use of the basin and its surroundings, which remains very much an operational waterway. The chains and barriers have difference purposes: the chains are for demarcation only (and primarily for vehicles at that), and they are not intended to exclude people from accessing the waterway because e.g. boaters are allowed to moor in this area; the barriers are intended to exclude people from the edge of the waterway and appear to do so adequately. We also believe lighting in the canal basin is sufficient and we note it is augmented by the lighting on adjacent land.” Source location 2016-0132-Response-by-Canal-and-River-Trust
Open published response
10 Mar 2016 Charles Alan Newby · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Failure to ensure appropriate installation of life rings at Lock 19 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
Charles Alan Newby · 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
Charles Alan Newby died after falling from the rear of a boat into the Calder River/Canal on 18 October 2015 while intoxicated with alcohol and not wearing a life jacket; he drowned despite attempts to retrieve him. The substantive concern was whether the installation of life rings at the Lock 19 location was appropriate.
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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate installation of life rings at Lock 19
Wider context from the report “I would ask the trust to carefully re-assess the appropriateness of the installation of life rings at the Lock 19 location .
” Open source report
Concerns raised 3 Lack of communication means within the tunnel View source Failure to provide safety information to all tunnel users View source Lack of requirement for persons in the tunnel to wear safety jackets or buoyancy aids 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
Michael Holgate · 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
Michael Holgate fell into the water after the narrow boat he was steering collided with the side of Harecastle Tunnel on 20 May 2014. The concerns included the lack of communication facilities in the tunnel, the absence of a requirement for people on board to wear buoyancy aids, the availability of safety helmets, and the safety information provided to tunnel users.
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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication means within the tunnel
Wider context from the report “1. There is no means of communication within the tunnel , I accept that mobile phones are not the like work but I would ask the Trust to explore the possibility of a telephone cable and a number of emergency telephones at strategic or regular points within the tunnel.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safety information to all tunnel users
Wider context from the report “4. I would ask generally that there be a review of the safety information given out, and made available to all, not just those driving the narrow boats .
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of requirement for persons in the tunnel to wear safety jackets or buoyancy aids
Wider context from the report “2. There is no requirement to wear safety jackets/buoyancy aids in the tunnel . These are mandated for narrow boat owners to carry on the boats. Would it not be possible to insist that all persons on board wear such safety equipment before they are allowed into the tunnel?
” 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 encouraging boaters to wear lifejackets or buoyancy aids, particularly in tunnels.
Verbatim wording from the response “2. Wearing of lifejackets or buoyancy aids
There is no mandatory requirement that lifejackets or buoyancy aids must be worn or carried on inland waterway vessels. The Trust does encourage their use on inland waterways, but the general view of many inland waterway boaters is that lifejackets or buoyancy aids are unnecessary, but this is an attitude that the Trust is trying to change. The Trust will continue to encourage boaters to wear them in the interests of their general safety whilst boating, and we will make particular reference to safety in tunnels. In direct response to this tragedy we will be encouraging the wearing of lifejackets at Harecastle Tunnel by means of the briefing given to boaters and their crew prior to tunnel entry.” Source location 2014-0357-Response-by-Canal-River-Trust
Open published response
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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 Complete the review of practicable in-tunnel communication systems.
Verbatim wording from the response “at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.” Source location 2014-0357-Response-by-Canal-River-Trust
Open published response
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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 Modify the Harecastle Tunnel briefing to emphasise lifejackets and explain temperature changes inside the tunnel.
Verbatim wording from the response “4. Review of safety information given out
The Harecastle tunnel briefing has been further modified to make clear the importance of wearing lifejackets particularly for the helmsman. Additional information about change of temperature in the tunnel is being included in the briefing as this has been identified as a particular risk of which boaters should be aware. These changes have been made.” Source location 2014-0357-Response-by-Canal-River-Trust
Open published response
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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 Modify tunnel portal signs across the network to recommend wearing lifejackets.
Verbatim wording from the response “As the majority of tunnels are unattended by Trust staff we will modify all existing tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will conduct an education campaign using our communication channels with boaters, about benefits of wearing of lifejackets/buoyancy aids. Although part of a continuous campaign we will complete this initial work by the 31st March 2015 which is the start of the main boating season.” Source location 2014-0357-Response-by-Canal-River-Trust
Open published response
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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 Conduct an education campaign through boater communication channels about lifejacket and buoyancy-aid benefits.
Verbatim wording from the response “As the majority of tunnels are unattended by Trust staff we will modify all existing tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will conduct an education campaign using our communication channels with boaters, about benefits of wearing of lifejackets/buoyancy aids. Although part of a continuous campaign we will complete this initial work by the 31st March 2015 which is the start of the main boating season.” Source location 2014-0357-Response-by-Canal-River-Trust
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 in-tunnel communication study could not be completed by the requested deadline because of its complexity.
Verbatim wording from the response “at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.” Source location 2014-0357-Response-by-Canal-River-Trust
Open published response
1 May 2014 Ian Sidney Martin · Prevention of Future Deaths report North Yorkshire (West)
View report summary
Concerns raised 2 Poor lighting in the area of the bridge View source Dangerous condition of steps leading from the canal bridge 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
Ian Sidney Martin · 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
Ian Sidney Martin fell on wet, slippery and worn steps on a canal bridge while travelling from Skipton Bus Station to meet his wife, sustaining a head injury from which he died in hospital later that day. The principal concerns were the dangerous condition of the steps and poor lighting around the bridge.
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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Poor lighting in the area of the bridge
Wider context from the report “(2) The poor lighting in the area of the bridge.
” 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 Canal & River Trust; that does not assign responsibility.
PFD Monitor interpretation Dangerous condition of steps leading from the canal bridge
Wider context from the report “(1) The condition of the steps from the canal bridge leading to Gas Street, Skipton, presents a danger to those using the bridge.
” Open source report
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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 Trust disputes that the steps were slippery or significantly worn, stating they were rough, in good condition and had little wear.
Verbatim wording from the response “We note from the Regulation 28 Report that on the date of the accident in January it had been raining and that being evening it would have been dark. The report states that the steps were wet, slippery and worn. The Trust's Health and Safety Advisor and I have both separately inspected the steps and are able to confirm that the step surface is rough in finish giving no indication of being likely to be slippery when wet. The surface of the steps is good with little sign of wear despite the footbridge taking very heavy footfall being located adjacent to the bus station into Skipton. There is a handrail on one side of the steps. Photographs that were taken by the Safety Advisor at the time of his visit are attached for your information.” Source location 2014-0196-Response-by-Canal-River-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations