22 Jan 2014 Paul Alan Rogerson · Prevention of Future Deaths report York City
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Concerns raised 11 Lack of a protocol for dealing with untidy or disordered rescue equipment View source Lack of hypothermia coverage in police first aid training View source Insufficient police familiarity with current Fire and Rescue water rescue methods View source Insufficient procedures for robust action against deliberate damage or theft of life buoys View source Insufficient police training in current river rescue and water safety protocols View source Failure to maintain securely positioned, intact and sufficiently long river rescue equipment View source Insufficient police communication of detailed information during river rescues View source Lack of a system for reporting missing life buoys View source Lack of prominent warning signs along the river bank and in accessible public house areas View source Insufficient checks on the condition of life buoys View source Failure to protect river rescue equipment from vandalism and weather View source See 8 more concerns
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Paul Alan Rogerson · 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
Paul Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for dealing with untidy or disordered rescue equipment
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray . There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Lack of hypothermia coverage in police first aid training
Wider context from the report “(5) North Yorkshire Police officers receive first aid training in CPR and wounds but Hypothermia is currently not covered .
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient police familiarity with current Fire and Rescue water rescue methods
Wider context from the report “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue .
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient procedures for robust action against deliberate damage or theft of life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft .
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient police training in current river rescue and water safety protocols
Wider context from the report “(3) North Yorkshire Police Officers may require further training in current protocols for River Rescue and Water Safety .
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain securely positioned, intact and sufficiently long river rescue equipment
Wider context from the report “(1) The position and protection of life buoys and throwing lines is inadequate . Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river . The integrity of this equipment is insufficiently protected from vandalism and the weather.
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient police communication of detailed information during river rescues
Wider context from the report “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control ; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue.
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for reporting missing life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy . North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent warning signs along the river bank and in accessible public house areas
Wider context from the report “(2) There are no warning signs in place along the river bank within the city walls in York . Only one was found in the course of my enquiry, this being attached to a life buoy harness and being smaller than an A4 piece of paper . Public Houses near the river are not encouraged to display prominent warning signs in areas that their customers have access to the water .
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient checks on the condition of life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys . It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 City of York Council; that does not assign responsibility.
PFD Monitor interpretation Failure to protect river rescue equipment from vandalism and weather
Wider context from the report “(1) The position and protection of life buoys and throwing lines is inadequate. Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river. The integrity of this equipment is insufficiently protected from vandalism and the weather .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations