14 Jan 2026 Oliver Anderson Long · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 5 Failure of consumers to check gambling-site licensing before access View source Failure of the self-exclusion scheme to cover overseas unlicensed gambling sites View source Lack of consumer awareness when accessing unlicensed gambling sites View source Lack of adequate public health information and warnings about unlicensed gambling-site risks View source Absence of gambling-harm protection features on unlicensed sites 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
Oliver Anderson Long · 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
Oliver Anderson Long, known as Ollie, was found dead on 23 February 2024 after travelling to East Sussex and leaving notes indicating an intention to take his own life from cliffs. He had a history including gambling disorder and, despite self-exclusion from licensed online gambling, was able to access unlicensed gambling sites. The principal concern was that unlicensed sites are outside the protections of regulated gambling and that there is inadequate public health information and warning about their risks.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of consumers to check gambling-site licensing before access
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it , particularly if the advert for the site is in a trusted space, such as on social media . The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains, and they may not be aware that these features are unlikely to be present on the site they are using.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of the self-exclusion scheme to cover overseas unlicensed gambling sites
Wider context from the report “I heard evidence from Ollie's family and the Gambling Commission in respect of the efficacy of the UK self-exclusion scheme, GamStop, which allows customers to bar themselves from all forms of legal and licenced online betting. This scheme, however, does not capture overseas unlicensed sites and people who have self-excluded (as Ollie did) may be able to access these sites or are being deliberately targeted by them .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of consumer awareness when accessing unlicensed gambling sites
Wider context from the report “Additionally, I heard evidence that consumers may not be aware that they have accessed an unlicensed site and in doing so have moved outside of the realm of the regulated 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate public health information and warnings about unlicensed gambling-site risks
Wider context from the report “There is, in my view, a lack of adequate public health information and warning relating to the risks posed by unlicenced gambling sites .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Absence of gambling-harm protection features on unlicensed sites
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it, particularly if the advert for the site is in a trusted space, such as on social media. The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains , and they may not be aware that these features are unlikely to be present on the site they are using .
” 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 Strengthen protections for people at risk through new safer-gambling requirements.
Verbatim wording from the response “23. The Government remains committed to tackling gambling-related harms. Working with the Gambling Commission, DCMS is committed to strengthening protections for those at risk through a range of new safer gambling requirements. DCMS and the other CGDs will continue to review the best available evidence to inform our decisions on how best to fulfil our commitment to tackle gambling-related harm.” Source location Response from Department of Culture Media and Sport
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 Raise awareness of harmful-gambling risks and support behaviour change through national campaigns.
Verbatim wording from the response “19. The levy also provides the opportunity to build the evidence for effective campaigns to tackle gambling-related harms. As part of their ongoing work, OHID intends to raise awareness of the risks of harmful gambling and support behaviour change through national campaigns. As per the 2023 white paper commitment, OHID also continues to work with DCMS and the Gambling Commission to strengthen informational messaging, including on the risks associated with gambling, with a view to replacing the current narrative based around ‘individual responsibility’. OHID will consider how best to include health information and warnings relating to the risks posed by unlicensed gambling sites, as part of this workstream. Further information will be shared on this as work progresses.” Source location Response from Department of Culture Media and Sport
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 Consider including warnings about unlicensed gambling-site risks in public-health messaging.
Verbatim wording from the response “19. The levy also provides the opportunity to build the evidence for effective campaigns to tackle gambling-related harms. As part of their ongoing work, OHID intends to raise awareness of the risks of harmful gambling and support behaviour change through national campaigns. As per the 2023 white paper commitment, OHID also continues to work with DCMS and the Gambling Commission to strengthen informational messaging, including on the risks associated with gambling, with a view to replacing the current narrative based around ‘individual responsibility’. OHID will consider how best to include health information and warnings relating to the risks posed by unlicensed gambling sites, as part of this workstream. Further information will be shared on this as work progresses.” Source location Response from Department of Culture Media and Sport
Open published response
×
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 Strengthen informational messaging about gambling risks through continued cross-departmental and regulatory work.
Verbatim wording from the response “19. The levy also provides the opportunity to build the evidence for effective campaigns to tackle gambling-related harms. As part of their ongoing work, OHID intends to raise awareness of the risks of harmful gambling and support behaviour change through national campaigns. As per the 2023 white paper commitment, OHID also continues to work with DCMS and the Gambling Commission to strengthen informational messaging, including on the risks associated with gambling, with a view to replacing the current narrative based around ‘individual responsibility’. OHID will consider how best to include health information and warnings relating to the risks posed by unlicensed gambling sites, as part of this workstream. Further information will be shared on this as work progresses.” Source location Response from Department of Culture Media and Sport
Open published response
Concerns raised 5 Inadequate visibility and wording of aerosol inhalation warnings View source Failure of social media platforms to control dangerous challenge content View source Lack of age restrictions on aerosol products and other products containing butane/propane propellant View source Failure to control toxic social media algorithms View source Age restrictions for social media platforms failing to account for hazardous content exposure 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
Oliver Luke Gorman · 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
Oliver Luke Gorman, aged 12, died at home on 5 May 2025 after inhaling butane gas from an aerosol spray. The report raised concerns about the lack of age restrictions on some products containing butane or propane, the adequacy of warnings about inhalation risks, and social media content promoting dangerous challenges.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility and wording of aerosol inhalation warnings
Wider context from the report “2. Adequacy of Warning
The warnings on the cans of ████████ of the danger/risk of inhaling the aerosol spray were, in my opinion, inadequate in terms of visibility and wording.
The warning was set in an area outline of about 12mm x 12mm, in black or white writing depending on the background colour of the can. It was lost amongst all the other information and writing on the can. At least the ‘inflammable content’ warning was outlined in red.
The warning stated “SOLVENT ABUSE CAN KILL INSTANTLY”.
Many people (both adults and children) may not equate inhalation of aerosol spray with solvent abuse. Thus, the warning does not appear to properly describe the risks of using/misusing using the product. That risk being inhalation of this aerosol spray can cause instant death.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of social media platforms to control dangerous challenge content
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of age restrictions on aerosol products and other products containing butane/propane propellant
Wider context from the report “1. No Age Restriction
The age restriction on the purchase of butane for refilling cigarette lighters (and the like) is 18 years of age. I understand the legislation is primarily aimed at preventing the misuse of butane.
The age restriction on the purchase of aerosol paints is 16 years of age. I understand that the legislation is aimed at reducing incidents of graffiti and preventing the misuse of butane/propane - ████████ as above.
There is no age restriction on the purchase of aerosol ████████ or other products containing butane/propane as the propellant, ████████ yet their misuse is as equally dangerous.
An age restriction on such products would also likely heighten parental awareness of the dangers of such products.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to control toxic social media algorithms
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Age restrictions for social media platforms failing to account for hazardous content exposure
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed , again via any toxic algorithms or any searches they may make.
” 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 Responsibility for online safety and responding to the incident lies with the Department for Science, Innovation and Technology.
Verbatim wording from the response “I can confirm that the Department for Science, Innovation and Technology (DSIT) leads on online safety. My colleague at the department, Minister ████████, Minister for AI and Online Safety in DSIT, is best placed to respond to you on this tragic incident, and will be writing to you regarding this within the statutory timeframe.” Source location Response from Department for Culture, Media and Sport
Open published response
23 Apr 2025 Christopher Brazil · Prevention of Future Deaths report Ceredigion
View report summary
Concerns raised 7 Lack of dosage guidance View source Unregulated and unlawful online sale of prescription-only medicines and controlled drugs View source Inadequate age and identity verification for access to restricted medicines and drugs View source Exposure of vulnerable and susceptible people to counterfeit or unsafe medications View source Rapid delivery by unlawful online pharmaceutical providers View source Lack of safeguards against incorrect self-diagnosis or consumer misuse View source Insufficient or absent verification of patient medical history before medication sales View source See 4 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
Christopher Brazil · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of dosage guidance
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Unregulated and unlawful online sale of prescription-only medicines and controlled drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs , which look legitimate and are found easily from simple online searches ; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Inadequate age and identity verification for access to restricted medicines and drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Exposure of vulnerable and susceptible people to counterfeit or unsafe medications
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Rapid delivery by unlawful online pharmaceutical providers
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards against incorrect self-diagnosis or consumer misuse
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient or absent verification of patient medical history before medication sales
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report
Concerns raised 8 Lack of emergency plans for organised open water swimming events View source Failure to maintain an accurate record of who is in the water and how many people are in the water View source Unclear responsibility for safety measures at organised open water swimming events View source Lack of specific health and safety guidance and compliance requirements for event risk assessments View source Lack of regulatory licensing and oversight for organised open water swimming events View source Lack of training requirements for open water swimming event organisers View source Lack of knowledge of participant competency and capability View source Failure to provide specific pre-session safety briefings View source See 5 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
Mr Joel Kenneth Ineson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency plans for organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate record of who is in the water and how many people are in the water
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time .
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems , emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for safety measures at organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of specific health and safety guidance and compliance requirements for event risk assessments
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance , nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory licensing and oversight for organised open water swimming events
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation .
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity . It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of training requirements for open water swimming event organisers
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of participant competency and capability
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific pre-session safety briefings
Wider context from the report “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session.
The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing , a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time.
It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.
Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing , risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers.
The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Open source report
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Cardiac Risk in the Young’s work to increase awareness of sudden cardiac death among sports participants.
Verbatim wording from the response “In terms of parental awareness of sudden cardiac death, I fully agree this is an important issue. Through Sport England, we have supported Cardiac Risk in the Young’s excellent work in seeking to increase awareness, for example, through Sport England’s site for clubs and community organisations, Buddle. More generally, Sport England signposts to and share case studies from the Joe Humphries Memorial Trust, British Heart Foundation and UK Coaching’s online learning.” Source location Response from Department for Digital, Culture, Media and Sport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation England Boxing is responsible for assessing and managing funding requirements for additional cardiac screening.
Verbatim wording from the response “With regard to funding, while I would be happy to raise the issue of cardiac screening with England Boxing, the department is not able to provide additional funding. England Boxing, the national governing body for community boxing in England, which is independent of the Government, is responsible for assessing and managing its funding requirements. England Boxing receives some of its income in the form of a grant from Sport England, the Government’s arm’s-length body for grassroots sport, but also receives income through other grants, fees and donations. I believe this gives them the avenues to explore any additional funding needed.” Source location Response from Department for Digital, Culture, Media and Sport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional departmental funding for cardiac screening cannot be provided.
Verbatim wording from the response “With regard to funding, while I would be happy to raise the issue of cardiac screening with England Boxing, the department is not able to provide additional funding. England Boxing, the national governing body for community boxing in England, which is independent of the Government, is responsible for assessing and managing its funding requirements. England Boxing receives some of its income in the form of a grant from Sport England, the Government’s arm’s-length body for grassroots sport, but also receives income through other grants, fees and donations. I believe this gives them the avenues to explore any additional funding needed.” Source location Response from Department for Digital, Culture, Media and Sport
Open published response
Concerns raised 7 Lack of minimum standards for medical support at child contact-sport matches View source Lack of baseline safeguarding and risk-management standards for child contact-sport matches View source Failure to undertake welfare checks on child contact-sport participants View source Lack of risk assessment for child contact-sport matches View source Failure to set maximum rounds or required periods of rest for child contact-sport matches View source Lack of guidance and regulation for contact sports involving children View source Lack of critical incident planning for child contact-sport matches View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Robert EASTWOOD · 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 29 June 2024, 15-year-old Alexander Eastwood became unresponsive after taking part in a kickboxing competition in Wigan. He was found to have a significant brain bleed, underwent surgery, and was declared deceased on 2 July 2024. The investigation identified concerns about the lack of guidance or regulation for children participating in contact sports, including minimum standards for medical support, rest periods, welfare checks, risk assessments and critical incident planning.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of minimum standards for medical support at child contact-sport matches
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required ,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of baseline safeguarding and risk-management standards for child contact-sport matches
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake welfare checks on child contact-sport participants
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken ,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for child contact-sport matches
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to set maximum rounds or required periods of rest for child contact-sport matches
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and regulation for contact sports involving children
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation .
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of critical incident planning for child contact-sport matches
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving children.
” Open source report
×
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 Direct regulation of sport does not fall within the government’s role or functions.
Verbatim wording from the response “You raised a number of concerns about the current system and I am keen to consider how best to address them. I am mindful that the government does not, and should not, regulate sport directly. However, I am concerned that the current system, which allows individual clubs to decide whether to affiliate to a National Governing Body and their associated standards, does not offer sufficient protection to children and parents.” Source location Response from Department For Culture, Media And Sport
Open published response
Concerns raised 7 Insufficient and ineffective track steward coverage for immediate assistance View source Absence of safety briefings for riders before track use View source Failure to control track access and maximum rider numbers View source Failure to segregate riders by skill, ability and bike power View source Failure to obtain riders’ next-of-kin and medical information before track access View source Lack of first-aid training for venue staff View source Absence of mandatory minimum safety and risk-management standards for motocross venues View source See 4 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
Simon Timothy Harding · 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
Simon Timothy Harding died after becoming separated from his motocross bike during a jump at Granfield Moto-Cross Track on 10 September 2022; the bike landed on his head, causing catastrophic and unsurvivable head injuries. Concerns included limited rider registration, no safety briefing, inadequate track regulation and stewarding, lack of rider segregation, and no first-aid training for venue staff. The report also identified a lack of mandatory minimum safety and risk-management standards for motocross venues as a risk of future deaths.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient and ineffective track steward coverage for immediate assistance
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Absence of safety briefings for riders before track use
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to control track access and maximum rider numbers
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to segregate riders by skill, ability and bike power
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain riders’ next-of-kin and medical information before track access
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of first-aid training for venue staff
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Absence of mandatory minimum safety and risk-management standards for motocross venues
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” Open source report
×
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 Current health and safety law does not require trained first-aid staff for participants and spectators, although guidance recommends considering them.
Verbatim wording from the response “HSE confirms that health and safety law as currently drafted does not place a requirement for trained first aid staff in relation to participants and spectators, though guidance does strongly recommend that such persons are included in any first aid needs assessment (HSG112, paragraph 159).” Source location Response from Department for Culture, Media and Sport
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 Practice tracks are not legally required to obtain authorisation to operate under the cited regulations.
Verbatim wording from the response “The ACU is able to authorise motocross events and venues such as practice tracks under the Motor Vehicles (Off Road Events) Regulations 1995, but this is not a requirement for practice tracks to operate. We understand from the ACU that this tragic incident took place at a private motocross practice facility at a venue not known to the ACU, and the event was not regulated or permitted by them or any other authorising body.” Source location Response from Department for Culture, Media and Sport
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 Individual motor sport event organisers are responsible for protecting participants’ safety and wellbeing.
Verbatim wording from the response “The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will always be risks associated with participating in motor sports, but it is important that robust measures are in place to reduce the risk of major injuries and health issues. It is the responsibility of individual motor sport event organisers to ensure that they protect the safety and wellbeing of their participants.” Source location Response from Department for Culture, Media and Sport
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 Event and venue operators have workplace health and safety duties under HSWA and associated regulations.
Verbatim wording from the response “Regardless of whether an event is regulated or authorised by a governing body, it is important to be clear that health and safety laws apply. The Health and Safety Executive (HSE) applies workplace health and safety law in relation to those with duties under the Health and Safety at” Source location Response from Department for Culture, Media and Sport
Open published response
Concerns raised 2 Ready availability of information providing instructions for ending one’s own life View source Lack of useful age verification on websites providing suicide guides 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.
×
AI-generated summary
Miranda Emilia Avanzi · 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
Miranda Emilia Avanzi was found unresponsive at home on 9 July 2024, partially suspended by a ligature, and her death was verified shortly afterwards. The principal concern was the ready availability online of detailed guides, including pictures and diagrams, giving instructions on ending one’s life by partial hanging, with limited age verification on some sites.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Ready availability of information providing instructions for ending one’s own life
Wider context from the report “The police found a printout from a blog post close to Ms Avanzi, while investigating the initial circumstances of her death. That 10-page document contains a step-by-step guide (with the inclusion of pictures and diagrams) on how to ‘succeed’ in ending one’s life by ‘partial hanging’. It was clear that this guide had been followed in the circumstances of this case.
While it is not obvious which website or forum this particular guide came from, it does cite numerous sources including ████████ and ████████. Just a basic search on Google or other search engines, reveals a significant number of forums and blogs, where users are able to obtain all manner of guides to completing suicide. Many of these sites have no, or no useful requirement for any type of age verification. The search engine suggests, at the top of the page, that help is available by dialling 999, which would appear to be an acknowledgement that the content resulting from the search is likely to be concerning and that person undertaking the search is likely already highly vulnerable.
I am concerned that the ready availability of such information, that provides clear instructions and advice for individuals wanting to end their own life at their own hands is of the utmost concern.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of useful age verification on websites providing suicide guides
Wider context from the report “The police found a printout from a blog post close to Ms Avanzi, while investigating the initial circumstances of her death. That 10-page document contains a step-by-step guide (with the inclusion of pictures and diagrams) on how to ‘succeed’ in ending one’s life by ‘partial hanging’. It was clear that this guide had been followed in the circumstances of this case.
While it is not obvious which website or forum this particular guide came from, it does cite numerous sources including ████████ and ████████. Just a basic search on Google or other search engines, reveals a significant number of forums and blogs, where users are able to obtain all manner of guides to completing suicide. Many of these sites have no, or no useful requirement for any type of age verification. The search engine suggests, at the top of the page, that help is available by dialling 999, which would appear to be an acknowledgement that the content resulting from the search is likely to be concerning and that person undertaking the search is likely already highly vulnerable.
I am concerned that the ready availability of such information, that provides clear instructions and advice for individuals wanting to end their own life at their own hands is of the utmost concern.
” Open source report
6 Jun 2024 Dominic Mark Chapman · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 5 Failure to implement, disseminate and enforce safe training session planning View source Lack of unequivocally clear weight-difference matching criteria View source Failure to apply weight-difference matching criteria View source Failure to carry out individualised venue risk assessments View source Failure to assess and oversee event medical cover risks View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dominic Mark Chapman · 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
Dominic Mark Chapman sustained a fatal head injury during a charity boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester on 9 April 2022, and died in hospital on 11 April 2022. The concerns identified included unclear and inconsistently applied criteria for matching opponents by weight, training that did not follow the intended pattern, and inadequate individualised risk assessments for events and medical cover.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to implement, disseminate and enforce safe training session planning
Wider context from the report “2) In his evidence to the inquest, ████████ ( sole director of Ultra Events Midlands Ltd., the franchisee responsible for organising the event on 9.4.22 ) said that while he left the specifics of the boxers’ 8 week training regime to the owner of the gym they used for this purpose “we don’t allow sparring until about halfway through training, then body sparring from Week 4, and head contact sparring from Week 5.”
By contrast, the gym owner, ████████, told the inquest:
“For the first week we worked on technique and fitness ( cardio work ); after 2 weeks, I added a bit of body sparring; after 3-4 weeks we added light sparring sessions with shots to the head.”
Other evidence from a number of the boxers themselves satisfied me that in fact the training provided for the event on 9.4.22 did not follow the pattern outlined by ████████ or anticipated by ████████ told the inquest that Ultra Events Ltd. has now produced Training Session planning, and that a proposed Training Workbook will require their coaches to sign a declaration confirming that they will follow this planning. These measures have not yet been brought into force by Ultra Events Ltd. , and I am concerned that unless and until they are brought into force, there is a risk that boxers will not receive the standard of training which Ultra Events Ltd. deems safe and appropriate .
It is currently unclear when these measures will be introduced, and how they will be disseminated and enforced so as to ensure that coaches and gyms used by Ultra Events Ltd. for charity white collar boxing events follow them to the letter.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of unequivocally clear weight-difference matching criteria
Wider context from the report “1) In the course of the inquest I was concerned that criteria set down by Ultra Events Ltd. to match opponents for bouts at the charity white collar boxing event on 9.4.22, specifically relating to the maximum allowable weight difference between boxers, were (a) insufficiently clear , and (b) not always applied by the event organiser. I heard evidence that Ultra Events Ltd. have since changed the wording of those criteria, but was satisfied that, as now drafted, the criteria still lack clarity .
For example, ████████ ( director and sole proprietor of Ultra Events Ltd. ) told the inquest that the intention behind the reworded criteria was that:
(a) any weight difference between boxers of up to 7kg would be acceptable;
and
(b) any weight difference between boxers in excess of 7kg would have to be referred to Ultra Events Ltd.'s head office for approval.
However, the criteria contained within the new workbook produced by Ultra Events Ltd. for use by those training and matching up boxers are not as unequivocally clear . For example, the workbook contains the statement: “If a match is over 7kg simply explain it on the fight order”.
I am concerned that instructions about weight differences between boxers taking part in charity white collar boxing bouts are important and should be unequivocal, and that coaches and event organisers should be clear about their responsibilities in this respect.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to apply weight-difference matching criteria
Wider context from the report “1) In the course of the inquest I was concerned that criteria set down by Ultra Events Ltd. to match opponents for bouts at the charity white collar boxing event on 9.4.22, specifically relating to the maximum allowable weight difference between boxers, were (a) insufficiently clear, and (b) not always applied by the event organiser . I heard evidence that Ultra Events Ltd. have since changed the wording of those criteria, but was satisfied that, as now drafted, the criteria still lack clarity.
For example, ████████ ( director and sole proprietor of Ultra Events Ltd. ) told the inquest that the intention behind the reworded criteria was that:
(a) any weight difference between boxers of up to 7kg would be acceptable;
and
(b) any weight difference between boxers in excess of 7kg would have to be referred to Ultra Events Ltd.'s head office for approval.
However, the criteria contained within the new workbook produced by Ultra Events Ltd. for use by those training and matching up boxers are not as unequivocally clear. For example, the workbook contains the statement: “If a match is over 7kg simply explain it on the fight order”.
I am concerned that instructions about weight differences between boxers taking part in charity white collar boxing bouts are important and should be unequivocal, and that coaches and event organisers should be clear about their responsibilities in this respect .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out individualised venue risk assessments
Wider context from the report “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.:
(a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them . I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes ;
(b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events. I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments. This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and oversee event medical cover risks
Wider context from the report “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.:
(a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them. I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes;
(b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events . I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments . This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment .
” Open source report
×
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 Individual boxing event organisers are responsible for protecting participants’ safety and wellbeing.
Verbatim wording from the response “The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will always be risks associated with participating in contact sports, but it is important that robust measures are in place to reduce the risk of major injuries and health issues. It is the responsibility of individual boxing event organisers to ensure that they protect the safety and wellbeing of their participants.” Source location Response from DCMS
Open published response
Concerns raised 7 Sale of online drugs in doses and quantities larger than ordinarily prescribed View source Failure to establish the suitability of online drug purchasers View source Failure to assess online drug suitability against the purchaser’s medical history View source Lack of regulation of online supply of powerful drugs View source Failure to inform the purchaser’s GP practice of online drug purchases View source Lack of safety and quality control for drugs supplied online View source Failure to control duplicate, excessive or frequent online drug purchases View source See 4 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
Nigel Walter DIXON · 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
Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Sale of online drugs in doses and quantities larger than ordinarily prescribed
Wider context from the report “Mr Dixon was able to purchase ████████ Zopiclone tablets ████████ online from a company ████████
The GP who gave evidence at the inquest described this as a “huge” amount of the drug. She confirmed that she would only prescribe 28 days’ worth of ████████ tablets in one go (████████ Mr Dixon was able to purchase). The selling of tablets which are a larger dose and in a much larger quantity than would ordinarily be prescribed online risks an accidental or intentional overdose of the drug and also risks the drug being sold on the black market.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the suitability of online drug purchasers
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser , nor a system to limit the amount or frequency of medication being purchased.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess online drug suitability against the purchaser’s medical history
Wider context from the report “The evidence of the GP was that the company who supplied these drugs to Mr Dixon did not contact the GP Practice to discuss their suitability or check Mr Dixon’s medical history , nor did they inform the GP’s Practice of the purchase.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of online supply of powerful drugs
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the purchaser’s GP practice of online drug purchases
Wider context from the report “The evidence of the GP was that the company who supplied these drugs to Mr Dixon did not contact the GP Practice to discuss their suitability or check Mr Dixon’s medical history, nor did they inform the GP’s Practice of the purchase .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of safety and quality control for drugs supplied online
Wider context from the report “The evidence of the GP is it is hard to prescribe safely to people who are supplementing their prescription drugs with online purchases. Further, she raised concerns about the safety and quality control of the drugs being supplied .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to control duplicate, excessive or frequent online drug purchases
Wider context from the report “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites , there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all . There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased .
” Open source report
Concerns raised 6 Related-question recommendations encouraging further consumption of the material View source Pop-up question functionality detracting from users appreciating the seriousness of the subject matter View source Upvoting functionality detracting from users appreciating the seriousness of the subject matter View source Question-following functionality encouraging further consumption of the material View source Insufficient monitoring and moderation of question-and-answer content View source Failure to restrict children’s access to content without age verification View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Isabella Shere · 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
Isabella Shere died at home in Lewisham, London, on 2 February 2023, aged 14. The inquest concluded that her death was suicide, with the medical cause recorded as asphyxia caused by hanging. The concerns included the availability and accessibility of information relating to methods of ending life on Quora, related content and user-engagement features encouraging further consumption, and insufficient monitoring or moderation.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Related-question recommendations encouraging further consumption of the material
Wider context from the report “(4) When viewing content ████████, a list of related questions is displayed, suggesting further similar content to users and encouraging further consumption of this material .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Pop-up question functionality detracting from users appreciating the seriousness of the subject matter
Wider context from the report “(6) There is an upvoting function which allows users to vote on the most useful answers to questions ████████. There is pop up question which can appear which asks ████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████████████
████████ Both of these functions detract from user appreciating the seriousness of the subject matter that is being consumed.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Upvoting functionality detracting from users appreciating the seriousness of the subject matter
Wider context from the report “(6) There is an upvoting function which allows users to vote on the most useful answers to questions ████████ . There is pop up question which can appear which asks ████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████████████
████████ Both of these functions detract from user appreciating the seriousness of the subject matter that is being consumed.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Question-following functionality encouraging further consumption of the material
Wider context from the report “(5) There is a function to follow questions ████████████████████████ encouraging further consumption of this material .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient monitoring and moderation of question-and-answer content
Wider context from the report “(7) There is not sufficient monitoring and/or moderation of the content of questions/answers in accordance with Quora’s own platform policies. ████████
████████████████████████████████████████████████████████████████████████
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” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict children’s access to content without age verification
Wider context from the report “(3) Children are able to access the site through search engines without being required to create an account and access content ████████ without being asked if they are an adult or being required to input their date of birth .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Ofcom to implement the Online Safety Act as quickly as possible to protect children from harmful online content.
Verbatim wording from the response “Part of our Government’s mission is to reduce the lives lost to suicide, and the Online Safety Act will help with this aim. My department is working closely with Ofcom to ensure that the Online Safety Act is implemented as quickly as possible so that children are protected from encountering harmful content online, especially at their most vulnerable moments, as happened with Miss Shere.” Source location 2024-0298 Response from Department for Science, Innovation and Technology
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ofcom is responsible for overseeing and enforcing the Online Safety Act regime.
Verbatim wording from the response “I am responding in place of the Department for Culture, Media and Sport, given my department’s responsibility for the online safety policy. The Online Safety Act received Royal Assent on 26 October 2023 and will place duties on tech companies to protect their users online, especially children. The Online Safety Act regime will be overseen and enforced by Ofcom, the independent regulator.” Source location 2024-0298 Response from Department for Science, Innovation and Technology
Open published response
Concerns raised 2 Unrestricted marketing and supply of publications providing clear instructions on methods of ending life View source Failure to regulate the supply of publications providing information on ending life 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.
×
AI-generated summary
Deborah Jane Cooper · 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
Deborah Jane Cooper, aged 61, died in circumstances suspected to involve carbon monoxide poisoning after apparatus was found and notes indicated an intention to end her life. The concern was that publications giving instructions on methods of ending one’s life were freely available through Amazon UK, with potentially inadequate regulation of their supply.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Unrestricted marketing and supply of publications providing clear instructions on methods of ending life
Wider context from the report “That duty has arisen in this case when I discovered that books giving clear instructions as to how an individual might want to end his or her life was freely available on the open market on the Amazon.co.uk website . I am concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end his or her life at their own hands is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives.
I have identified 2 publication that give such advice and there may be more currently being marketed on the Amazon.co.uk website .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to regulate the supply of publications providing information on ending life
Wider context from the report “That duty has arisen in this case when I discovered that books giving clear instructions as to how an individual might want to end his or her life was freely available on the open market on the Amazon.co.uk website. I am concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end his or her life at their own hands is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives .
I have identified 2 publication that give such advice and there may be more currently being marketed on the Amazon.co.uk website.
” Open source report
Concerns raised 3 Failure to regulate and verify online sales of prescription-only sedative medication View source Online availability of medication providing means for suicide or self-harm View source Facilitation of dangerous medication addictions through online availability of sedative medication 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.
×
AI-generated summary
KIMBERLY ANNA LIU · 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
Kimberly Anna Liu, who had become addicted to sedative and other medications, was found unresponsive at home on 7 February 2023 and was pronounced dead. The inquest concluded that this was a drug-related death caused by mixed drug toxicity. The principal concern was that unregulated websites supplied prescription-only sedative medications without prescriptions or adequate checks, potentially exploiting vulnerable people with medication addictions and providing means for suicide or self-harm.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to regulate and verify online sales of prescription-only sedative medication
Wider context from the report “The evidence revealed that from at least 2019, Kimberly Liu had regularly accessed websites specifically aimed at selling prescription-only medications (predominantly medications with a sedative effect) that allowed repeat orders on the same day and did not require a prescription . Those websites included the following:
▮ ████████
▮ ████████
▮ ████████
Despite the different URLs some of the websites appear to be operated by the same company and/or individual(s), in that ordering using an identical WhatsApp number (████████) was also permitted.
Correspondence from the websites, following an order being placed, included messaging that suggested that the operator(s) knew that their supply of such medication was likely to arouse regulatory suspicion. By way of example, messaging received in emails following the placing of an order, included the following:
• ‘This is to inform you that usage of the name “Sleeping Tablets” during the payment at the banks is prohibited. Kindly do not use the brand name as it can be harmful for us.’
• ‘DO NOT MENTION THE PRODUCT OR WEBSITE WHEN MAKING PAYMENT.’
On one occasion in December 2021, the same website permitted identical orders of ████████ tablets within nine minutes of each other, without question or checks . Three days later a further order of ████████ ████████ was again permitted without any query.
The concern here is that these websites, and potentially other similar websites, are not only operating without regulation, but that they appear to exploit already vulnerable individuals by facilitating an almost unseen feeding of dangerous medication addictions thereby placing those individuals in grave danger.
Although the inquest I heard did not concern a death by suicide, the additional concern is that these websites could also be seen to equip people with the means to complete suicide.
I believe that consideration ought to be given to the impact that the availability of such websites has on the population at large, together with the significantly increased risks to those who have developed an addiction to such medications or may even be contemplating acts of self-harm. I also believe that consideration ought to be given to whether and what action(s) could be taken to remove or limit access to or the availability of such websites.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Online availability of medication providing means for suicide or self-harm
Wider context from the report “The evidence revealed that from at least 2019, Kimberly Liu had regularly accessed websites specifically aimed at selling prescription-only medications (predominantly medications with a sedative effect) that allowed repeat orders on the same day and did not require a prescription. Those websites included the following:
▮ ████████
▮ ████████
▮ ████████
Despite the different URLs some of the websites appear to be operated by the same company and/or individual(s), in that ordering using an identical WhatsApp number (████████) was also permitted.
Correspondence from the websites, following an order being placed, included messaging that suggested that the operator(s) knew that their supply of such medication was likely to arouse regulatory suspicion. By way of example, messaging received in emails following the placing of an order, included the following:
• ‘This is to inform you that usage of the name “Sleeping Tablets” during the payment at the banks is prohibited. Kindly do not use the brand name as it can be harmful for us.’
• ‘DO NOT MENTION THE PRODUCT OR WEBSITE WHEN MAKING PAYMENT.’
On one occasion in December 2021, the same website permitted identical orders of ████████ tablets within nine minutes of each other, without question or checks. Three days later a further order of ████████ ████████ was again permitted without any query.
The concern here is that these websites, and potentially other similar websites, are not only operating without regulation, but that they appear to exploit already vulnerable individuals by facilitating an almost unseen feeding of dangerous medication addictions thereby placing those individuals in grave danger.
Although the inquest I heard did not concern a death by suicide, the additional concern is that these websites could also be seen to equip people with the means to complete suicide .
I believe that consideration ought to be given to the impact that the availability of such websites has on the population at large, together with the significantly increased risks to those who have developed an addiction to such medications or may even be contemplating acts of self-harm. I also believe that consideration ought to be given to whether and what action(s) could be taken to remove or limit access to or the availability of such websites.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Facilitation of dangerous medication addictions through online availability of sedative medication
Wider context from the report “The evidence revealed that from at least 2019, Kimberly Liu had regularly accessed websites specifically aimed at selling prescription-only medications (predominantly medications with a sedative effect) that allowed repeat orders on the same day and did not require a prescription. Those websites included the following:
▮ ████████
▮ ████████
▮ ████████
Despite the different URLs some of the websites appear to be operated by the same company and/or individual(s), in that ordering using an identical WhatsApp number (████████) was also permitted.
Correspondence from the websites, following an order being placed, included messaging that suggested that the operator(s) knew that their supply of such medication was likely to arouse regulatory suspicion. By way of example, messaging received in emails following the placing of an order, included the following:
• ‘This is to inform you that usage of the name “Sleeping Tablets” during the payment at the banks is prohibited. Kindly do not use the brand name as it can be harmful for us.’
• ‘DO NOT MENTION THE PRODUCT OR WEBSITE WHEN MAKING PAYMENT.’
On one occasion in December 2021, the same website permitted identical orders of ████████ tablets within nine minutes of each other, without question or checks. Three days later a further order of ████████ ████████ was again permitted without any query.
The concern here is that these websites, and potentially other similar websites, are not only operating without regulation, but that they appear to exploit already vulnerable individuals by facilitating an almost unseen feeding of dangerous medication addictions thereby placing those individuals in grave danger .
Although the inquest I heard did not concern a death by suicide, the additional concern is that these websites could also be seen to equip people with the means to complete suicide.
I believe that consideration ought to be given to the impact that the availability of such websites has on the population at large, together with the significantly increased risks to those who have developed an addiction to such medications or may even be contemplating acts of self-harm. I also believe that consideration ought to be given to whether and what action(s) could be taken to remove or limit access to or the availability of such websites.
” Open source report
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods View source See 3 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
Chloe Elizabeth MACDERMOTT · 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
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural use.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable adults .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” Open source report
Concerns raised 1 Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites 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.
×
AI-generated summary
Bronwen Grace MORGAN (BM) · 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
Bronwen Morgan, who was under the care of local mental health services, travelled to a hotel on 27 August 2020 and was later found there by emergency services. She was conveyed to hospital, where she died from the toxic consequences of a substance after resuscitation attempts failed. The principal concern was that an online forum and potentially similar sites enabled vulnerable people to discuss, obtain information about, and acquire means for self-harm or suicide.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites
Wider context from the report “The evidence revealed that as from at least February 2020, BM had registered with, & was engaging in discussion forums ████████ This website was mentioned in an earlier PFD Report dated 3.12.19 (copy annexed).
The engagement that BM had with the website encompassed her discussing & seeking advice from fellow users in respect of, methods of self-harm/suicide including the purchasing & use of the substance ████████. This was the substance used by BM which led to her death.
The concern here is that this site & potentially similar self-harm & suicide “facilitating or promoting” sites are accessible/available to those, such as BM who are vulnerable, due to their diagnosed, or otherwise mental illness & provided with an outlet/forum to source & acquire information that potentially equips them with the knowledge & means to either complete suicide, or place them in grave/greater danger of doing so.
I believe that consideration ought to be given to the impact such access/availability has upon those vulnerable individuals researching/contemplating acts of self-harm & whether, & what action(s) may be taken to remove/limit/mitigate/educate such access/availability.
” Open source report
Concerns raised 5 Lack of authoritative guidance on permitted front-of-house drug testing View source Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions View source Lack of reliable records of drug-related festival casualties View source Lack of governing oversight of music festivals View source Lack of accurate information about the number of under-18 festival attendees 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
David Joseph Celino · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of authoritative guidance on permitted front-of-house drug testing
Wider context from the report “(6) Various witnesses raised the issue of “Front of House” drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office , along with clarification as to exactly what is permitted .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions
Wider context from the report “(5) Evidence at the inquest indicated David Celino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino’s friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as “normal”.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable records of drug-related festival casualties
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties , which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of governing oversight of music festivals
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate information about the number of under-18 festival attendees
Wider context from the report “(1) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, naïve teenagers exposed to possible exploitation by drug dealers, was not appreciated.
” Open source report
Concerns raised 3 Reliance on industry regulatory standards rather than current good or best practice for gambling-customer protection View source Failure of the gambling-monitoring algorithm to flag problem gamblers View source Inadequacy of player protection tools to provide meaningful interaction or intervention for worsening problem gamblers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Anthony Ashton · 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
Luke Anthony Ashton, a 40-year-old man, was discovered deceased at Carnegie House, Swinton, on 22 April 2021, and his death was confirmed at the scene. The inquest found that he had a longstanding gambling disorder and that his gambling activity, deposits and losses were most intensive in the 10 weeks before his death. Concerns included the adequacy of player protection tools, Betfair’s failure to identify his worsening gambling through its monitoring algorithm, and the lack of meaningful intervention or interaction.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Reliance on industry regulatory standards rather than current good or best practice for gambling-customer protection
Wider context from the report “3) I remain concerned that, as was apparent through the evidence of a senior employee witness during the course of the inquest, the operator Betfair appears to judge the extent of its responsibilities to gambling customers solely with regard to industry (regulatory) standards, rather than current good or best practice in order to prevent further harming problem gamblers, or those who, as a result of their changing practices and patterns are likely to become problem gamblers.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of the gambling-monitoring algorithm to flag problem gamblers
Wider context from the report “2) I remain concerned that the algorithm devised and operated by Betfair, to assist its staff in, amongst other things, observing and monitoring the gambling patterns and practices of its customers, failed to flag up Mr. Ashton as a problem gambler , despite the increases in his time online (gambling) the value of his deposits and the size of his losses, in part because his gambling practices, even in the last 10-12 weeks of his life, were deemed not to be exceptional, when averaged among gambling customers, generally.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of player protection tools to provide meaningful interaction or intervention for worsening problem gamblers
Wider context from the report “1) I remain concerned that the player protection tools, as mentioned above, were and are inadequate to protect a person such as Mr. Ashton, who was a problem gambler with a worsening problem , specifically that such tools do not amount to any or any meaningful interaction with the gambler, or any intervention into the practices of the gambler .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen customer-controlled gambling transaction blocks, including expanding coverage to non-card payment methods.
Verbatim wording from the response “8. As an additional protection, we will also continue work with the gambling and financial services sectors to make customer-controlled gambling transaction blocks as robust as possible, for instance by expanding them to cover non-card payment methods. Finally, the Gambling Commission’s new customer interaction requirements put a specific obligation on operators to consider a customer’s use of gambling management tools when assessing for signs of risk (outlined below). I am hopeful that these changes can and will address your concerns.” Source location Response from Department for Culture, Media and Sport
Open published response
×
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 Develop and introduce a maximum stake limit for online slots games.
Verbatim wording from the response “5. A number of the proposals in the white paper relate to the protection of online gamblers, and these are being introduced in addition to the specific changes outlined below in relation to your concerns. For example, we are creating new obligations on operators to conduct checks to understand if a customer’s gambling is likely to be harmful in the context of their financial circumstances, seeking to mandate participation in a cross-operator harm prevention system based on data sharing, bringing in new rules to make online games safer by design, and introducing a maximum stake limit for online slots games. We will also continue to tighten rules on advertising and marketing, tackling aggressive practices like using bonuses in ways which exacerbate harms, and working with health and behavioural science experts to develop independent messaging that raises awareness of the risks of gambling.” Source location Response from Department for Culture, Media and Sport
Open published response
×
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 Develop a cross-operator harm-prevention system requiring participation and data sharing.
Verbatim wording from the response “5. A number of the proposals in the white paper relate to the protection of online gamblers, and these are being introduced in addition to the specific changes outlined below in relation to your concerns. For example, we are creating new obligations on operators to conduct checks to understand if a customer’s gambling is likely to be harmful in the context of their financial circumstances, seeking to mandate participation in a cross-operator harm prevention system based on data sharing, bringing in new rules to make online games safer by design, and introducing a maximum stake limit for online slots games. We will also continue to tighten rules on advertising and marketing, tackling aggressive practices like using bonuses in ways which exacerbate harms, and working with health and behavioural science experts to develop independent messaging that raises awareness of the risks of gambling.” Source location Response from Department for Culture, Media and Sport
Open published response
×
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 Create operator obligations to assess whether customers’ gambling is harmful in the context of their financial circumstances.
Verbatim wording from the response “5. A number of the proposals in the white paper relate to the protection of online gamblers, and these are being introduced in addition to the specific changes outlined below in relation to your concerns. For example, we are creating new obligations on operators to conduct checks to understand if a customer’s gambling is likely to be harmful in the context of their financial circumstances, seeking to mandate participation in a cross-operator harm prevention system based on data sharing, bringing in new rules to make online games safer by design, and introducing a maximum stake limit for online slots games. We will also continue to tighten rules on advertising and marketing, tackling aggressive practices like using bonuses in ways which exacerbate harms, and working with health and behavioural science experts to develop independent messaging that raises awareness of the risks of gambling.” Source location Response from Department for Culture, Media and Sport
Open published response
×
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 Introduce rules requiring online games to be safer by design.
Verbatim wording from the response “5. A number of the proposals in the white paper relate to the protection of online gamblers, and these are being introduced in addition to the specific changes outlined below in relation to your concerns. For example, we are creating new obligations on operators to conduct checks to understand if a customer’s gambling is likely to be harmful in the context of their financial circumstances, seeking to mandate participation in a cross-operator harm prevention system based on data sharing, bringing in new rules to make online games safer by design, and introducing a maximum stake limit for online slots games. We will also continue to tighten rules on advertising and marketing, tackling aggressive practices like using bonuses in ways which exacerbate harms, and working with health and behavioural science experts to develop independent messaging that raises awareness of the risks of gambling.” Source location Response from Department for Culture, Media and Sport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The regulatory framework is outcomes-based and requires operators to pursue licensing objectives, not merely comply with minimum standards.
Verbatim wording from the response “16. This concern is addressed to Betfair specifically, however in seeking to provide a full response I recognise the concern that other operators may similarly seek only to meet the minimum standards of regulation and legislation.” Source location Response from Department for Culture, Media and Sport
Open published response
Concerns raised 4 Risk of future deaths from illegal flights View source Failure of relevant organisations to communicate illegal-flight risks to their members View source Insufficient CAA powers for investigating and enforcing aviation regulation breaches View source Lack of effective public guidance about illegal flights and their risks View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emiliano Raul Sala · 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
Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Risk of future deaths from illegal flights
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights , and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant organisations to communicate illegal-flight risks to their members
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members , and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations . I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role .
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of effective public guidance about illegal flights and their risks
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public , especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them . I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share current aviation safety guidance and supporting information with sports and music organisations for dissemination to private-flight charterers.
Verbatim wording from the response “However, in light of your recommendation, we have discussed this case with the DfT and CAA to assess the most relevant guidance for those involved in sport and music. The CAA recommended their latest guidance alongside a leaflet with further information. We have shared these with the sports organisations your Regulation 28 report was sent to for dissemination to anyone who may be chartering a private flight, as well as Live Music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians’ Union.” Source location Response from Department for Digital, Culture Media and Sports
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CAA regulates aviation safety, while ministerial responsibility lies with the Department for Transport, not DCMS.
Verbatim wording from the response “With regard to your recommendation, the Civil Aviation Authority (CAA) is responsible for the regulation of aviation safety in the United Kingdom, and Ministerial responsibility lies with the Department for Transport (DfT). Therefore, it would not be appropriate for DCMS to conduct a review of aviation guidance. You will be aware that the DfT are currently reviewing the powers available to the CAA in investigating breaches of aviation regulations.” Source location Response from Department for Digital, Culture Media and Sports
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducting a review of aviation guidance falls outside DCMS’s functions because aviation safety regulation is the CAA’s responsibility.
Verbatim wording from the response “With regard to your recommendation, the Civil Aviation Authority (CAA) is responsible for the regulation of aviation safety in the United Kingdom, and Ministerial responsibility lies with the Department for Transport (DfT). Therefore, it would not be appropriate for DCMS to conduct a review of aviation guidance. You will be aware that the DfT are currently reviewing the powers available to the CAA in investigating breaches of aviation regulations.” Source location Response from Department for Digital, Culture Media and Sports
Open published response
Concerns raised 11 Continuing gaps in gambling-related information View source Lack of medical professional training in diagnosing and treating gambling addiction View source Failure of gambling regulation to stop gambling by people with obvious gambling addiction View source Lack of understanding that gambling addiction is not the individual's fault View source Continuing gaps in gambling warnings View source Lack of gambling education for school children View source Insufficient gambling warnings to prevent gambling View source Insufficient information to prevent gambling or inform people about available help and treatment View source Insufficient GP training and knowledge to deal effectively with gambling problems View source Continuing gaps in gambling addiction treatment View source Insufficient treatment for gambling addiction View source See 8 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
JACK WILLIAM RAMSEY RITCHIE · 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
Jack William Ramsey Ritchie died on 22 November 2017 from multiple injuries after an incident in Hanoi, Vietnam, in which the evidence indicated he intended to take his own life. The report raised concerns about gambling regulation, warnings, information, treatment, professional training, the stigma associated with gambling addiction, and limited education for young people about gambling harms.
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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling-related information
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of medical professional training in diagnosing and treating gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of gambling regulation to stop gambling by people with obvious gambling addiction
Wider context from the report “- That the system of regulation in force at the time of his death did not stop Jack gambling at a point when he was obviously addicted to gambling
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that gambling addiction is not the individual's fault
Wider context from the report “- Jack didn’t understand that being addicted to gambling wasn’t his fault . That lack of understanding lead to feelings of shame and hopelessness which in turn, contributed to him feeling suicidal
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling warnings
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings , information, training and treatment, the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of gambling education for school children
Wider context from the report “- The evidence was that young people were the most at risk from the harms of gambling yet there was and still appears to be, very little education for school children on the subject .
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient gambling warnings to prevent gambling
Wider context from the report “- The warnings Jack received were insufficient to prevent him gambling
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient information to prevent gambling or inform people about available help and treatment
Wider context from the report “- The information available to Jack was insufficient to prevent him gambling or to inform him of the help / treatments available
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP training and knowledge to deal effectively with gambling problems
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems . This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling addiction treatment
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Insufficient treatment for gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” Open source report
22 Nov 2021 BERENICE NADIKA BELL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 The single largest cause of death among people under 35 in the UK View source Access to various family and mental health professionals View source Access to services before death among children who subsequently died from the same cause View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BERENICE NADIKA BELL · 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
Berenice had booked into an Airbnb and was found dead there on 20 May 2021 after failing to check out, having left a note. Evidence indicated that she had sought psychotherapy in April 2021 and had been feeling anxious and depressed; she had also lost her life savings after being scammed. Concerns included the role of ████████ in deaths among people under 35 and evidence that Berenice had accessed various ████████ family and mental health professionals, alongside reports of similar post-death findings by other families.
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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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation The single largest cause of death among people under 35 in the UK
Wider context from the report “(1) ████████ is the single largest cause of death in the UK for people under 35.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Access to various family and mental health professionals
Wider context from the report “(2) Evidence was provided by the family that Berenice had accessed various ████████ family and mental health professionals.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Access to services before death among children who subsequently died from the same cause
Wider context from the report “(3) The family have discovered through a support group that other parents who have lost their children to ████████ have also discovered, after the deaths of their children, that their own children were also accessing ████████ before they died.
” 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 Consider the Law Commission’s recommendations on new or replacement offences for harmful online communications, including self-harm communications.
Verbatim wording from the response “We are also ensuring that criminal law is fit for purpose to account for harmful and dangerous communications online. The Department for Digital, Culture, Media and Sport sponsored a Law Commission review of harmful online communications. As part of this review, the government asked the Law Commission to examine how the criminal law will address the encouragement or assistance of self-harm. The Law Commission has published its final report, recommending several new or replacement offences to capture these types of communications online, including a new self-harm offence. The government is considering the Law Commission’s recommendations and will set out our position in due course.” Source location 2021-0404-Response-from-Dept-for-Digital-Culture-Media-Sport_Published.pdf
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging suicide and self-harm prevention stakeholders through wider suicide prevention and online safety work.
Verbatim wording from the response “The Department for Health and Social Care’s strategic partnership with suicide and self-harm prevention experts, led by the Samaritans, continues to tackle this content and support vulnerable users of their platforms. This partnership is undertaking research to develop our understanding of harmful suicide and self-harm content, produce guidance for industry and establish an advice and reporting service. Samaritans have also released Managing self-harm and suicide content online, a set of guidelines for sites and platforms hosting user-generated content, which sets out a framework of best practice principles to support platforms to manage self-harm and suicide content in a safe and sensitive way. The government continues to engage with these stakeholders as part of wider suicide prevention work and the online safety framework.” Source location 2021-0404-Response-from-Dept-for-Digital-Culture-Media-Sport_Published.pdf
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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 Introduce the Online Safety Bill as soon as possible after considering the Joint Committee’s recommendations.
Verbatim wording from the response “The draft Bill has been subject to pre-legislative scrutiny by a Joint Committee. The Joint Committee reported with their recommendations on 14 December. We will now fully consider the Committee’s recommendations and are committed to introducing the Bill as soon as possible after that. In the meantime we are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation.” Source location 2021-0404-Response-from-Dept-for-Digital-Culture-Media-Sport_Published.pdf
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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 Sponsor a Law Commission review of how criminal law should address encouragement or assistance of self-harm online.
Verbatim wording from the response “We are also ensuring that criminal law is fit for purpose to account for harmful and dangerous communications online. The Department for Digital, Culture, Media and Sport sponsored a Law Commission review of harmful online communications. As part of this review, the government asked the Law Commission to examine how the criminal law will address the encouragement or assistance of self-harm. The Law Commission has published its final report, recommending several new or replacement offences to capture these types of communications online, including a new self-harm offence. The government is considering the Law Commission’s recommendations and will set out our position in due course.” Source location 2021-0404-Response-from-Dept-for-Digital-Culture-Media-Sport_Published.pdf
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 Work with Ofcom to minimise the time required to implement the online safety framework after legislation is passed.
Verbatim wording from the response “The draft Bill has been subject to pre-legislative scrutiny by a Joint Committee. The Joint Committee reported with their recommendations on 14 December. We will now fully consider the Committee’s recommendations and are committed to introducing the Bill as soon as possible after that. In the meantime we are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation.” Source location 2021-0404-Response-from-Dept-for-Digital-Culture-Media-Sport_Published.pdf
Open published response
17 Jul 2020 Jerrelle MCKENZIE · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3 Social media influence promoting Dinitrophenol consumption for weight loss and body image View source Harmful effects of Dinitrophenol View source Continued Internet access to banned Dinitrophenol 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
Jerrelle MCKENZIE · 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
Jerrelle MCKENZIE was admitted to Luton & Dunstable Hospital on 3 August 2019 after taking an overdose of Dinitrophenol (DNP), and died there later that evening. The concerns were that DNP was banned in the UK because of its harmful effects, that social media may have influenced his use of it to lose weight and improve his body image, and that he accessed it through the internet or dark web.
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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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Social media influence promoting Dinitrophenol consumption for weight loss and body image
Wider context from the report “(1) The Deceased had taken an overdose of Dinitrophenol (DNP) yet this drug was banned in the UK in 1938 due to its harmful effects;
(2) It appears that the Deceased, who was an intelligent and thoughtful individual, was drawn to consuming DNP to lose weight and improve his body image and it was believed that this was through the influence of social media ;
(3) Despite its ban, it is thought that the Deceased was able access the DNP over the Internet (“dark web”)
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Harmful effects of Dinitrophenol
Wider context from the report “(1) The Deceased had taken an overdose of Dinitrophenol (DNP) yet this drug was banned in the UK in 1938 due to its harmful effects ;
(2) It appears that the Deceased, who was an intelligent and thoughtful individual, was drawn to consuming DNP to lose weight and improve his body image and it was believed that this was through the influence of social media;
(3) Despite its ban, it is thought that the Deceased was able access the DNP over the Internet (“dark web”)
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Continued Internet access to banned Dinitrophenol
Wider context from the report “(1) The Deceased had taken an overdose of Dinitrophenol (DNP) yet this drug was banned in the UK in 1938 due to its harmful effects;
(2) It appears that the Deceased, who was an intelligent and thoughtful individual, was drawn to consuming DNP to lose weight and improve his body image and it was believed that this was through the influence of social media;
(3) Despite its ban, it is thought that the Deceased was able access the DNP over the Internet (“dark web”)
” Open source report
Concerns raised 2 Availability of online forum advice on misleading mental health professionals to avoid mental health detention View source Availability of online forum advice on methods of taking one's life 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
Callie 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
Callie Lewis had chronic suicidal ideation and was actively planning to end her life, later dying by carbon monoxide poisoning after travelling to a remote location. The inquest concluded that her death was suicide by carbon monoxide poisoning contributed to by neglect. A substantive concern was that an online pro-suicide forum provided advice on methods of suicide and on misleading mental health professionals, frustrating assessment and enabling her to take her life.
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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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Availability of online forum advice on misleading mental health professionals to avoid mental health detention
Wider context from the report “(1) Callie was using an online suicide forum, ████████ (the forum now appears under the internet address ████████.Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act and also how to perfect the methods of taking her life that she had been considering. She was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her life
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Availability of online forum advice on methods of taking one's life
Wider context from the report “(1) Callie was using an online suicide forum, ████████ (the forum now appears under the internet address ████████.Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act and also how to perfect the methods of taking her life that she had been considering. She was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her life
” 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 Establish an independent regulator to oversee online services’ compliance with the duty of care and enforce safety requirements.
Verbatim wording from the response “The Online Harms White Paper, published in April 2019, set out the government's plans for world-leading legislation to make the UK the safest place in the world to be online. This will make companies more responsible for their users' safety online, especially children and other vulnerable groups. While some companies have taken steps to address harmful content on their platforms, including to reduce the risk posed by suicide and self-harm related content, these voluntary measures have not delivered the necessary improvements. Under our proposed approach, a new duty of care will make companies take more responsibility for the safety of their users, and tackle harm caused by content or activity on their services. Compliance with this duty of care will be overseen by an independent regulator.” Source location 2019-0414-Response-from-DCMS
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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 legislation establishing a duty of care requiring online services to protect users from harmful content and activity.
Verbatim wording from the response “The Online Harms White Paper, published in April 2019, set out the government's plans for world-leading legislation to make the UK the safest place in the world to be online. This will make companies more responsible for their users' safety online, especially children and other vulnerable groups. While some companies have taken steps to address harmful content on their platforms, including to reduce the risk posed by suicide and self-harm related content, these voluntary measures have not delivered the necessary improvements. Under our proposed approach, a new duty of care will make companies take more responsibility for the safety of their users, and tackle harm caused by content or activity on their services. Compliance with this duty of care will be overseen by an independent regulator.” Source location 2019-0414-Response-from-DCMS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Secretary of State lacks the power to prevent harmful websites from operating.
Verbatim wording from the response “The government expects companies to take action now to tackle harmful content or activity on their services. Indeed, there are already some existing arrangements between individual companies and charities to improve the identification and removal of this content when it is reported, and services that signpost help and supportive content to their users. As Secretary of State I do not, however, have the power to prevent the operation of harmful websites.” Source location 2019-0414-Response-from-DCMS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The new regulator will be responsible for producing codes of practice on online suicide and self-harm content.
Verbatim wording from the response “Some of the areas the regulator could include in a code of practice include setting out the steps a company might take to ensure that users who have been exposed to this content are able to access adequate support; ensuring that companies work with experts in suicide prevention so that their policies and practices protect the most vulnerable; and processes to stop algorithms promoting self-harm or suicide content to users. It will be for the new regulator to produce codes of practice when it becomes operational.” Source location 2019-0414-Response-from-DCMS
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Concerns raised 2 Failure to obtain riverfront coastguard location references during emergency calls View source Failure to promptly triage river emergencies and involve appropriate waterborne assets 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
Robert Cobbina · 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
Robert Cobbina entered the River Thames on 2 November 2018 and was later retrieved from the river and pronounced dead at the shore. The concerns related to emergency-call handling, including whether callers were prompted to request coastguard or other waterborne assistance and to provide riverfront location references, potentially delaying the deployment of appropriate assets.
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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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain riverfront coastguard location references during emergency calls
Wider context from the report “1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently involve other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or .
2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference .
It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible, and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.
” 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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly triage river emergencies and involve appropriate waterborne assets
Wider context from the report “1. That neither the initial caller, nor a passer-by who continued the call with the emergency control room, were prompted to request the coastguard or other waterborne assistance despite making clear that the emergency related to a person in the river. While it is understood that each service can subsequently involve other services as required, the concern inevitably arises that there was a potentially significant delay in involving the appropriate assets to locate Mr Cobbina which could have been avoided at the point at which the call was triaged and/or .
2. That neither the initial caller, nor the passer-by were prompted to identify existing signage placed along the riverfront providing a coastguard location reference to be provided in an emergency situation to enable a swift and precise arrival on scene in the absence of a normal address reference.
It is acknowledged that this may have been an isolated instance but the concern remains that callers identifying an emergency related to someone in the river may not always be sufficiently interrogated, appropriately triaged, or be served with the appropriate assets as soon as may be possible , and that in other circumstances there is a risk that death will occur unless action is taken to ensure this is not systemic.
” Open source report
29 Apr 2019 Bradley Robert Michael Trevarthen · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1 Young persons’ access to abundant and easily accessible self-harm and suicide information that normalises such actions 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
Bradley Robert Michael Trevarthen · 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
Bradley Robert Michael Trevarthen, aged 13, was found suspended from a bannister at his home on 10 January 2018 and later died in hospital. The principal concern was the availability and accessibility of online material about self-harm, suicide and suicide methods, which was considered unsuitable for young people and potentially normalising such actions.
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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 Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Young persons’ access to abundant and easily accessible self-harm and suicide information that normalises such actions
Wider context from the report “It will come as no surprise that my concern here relates to the internet and the regulation of it. Brad had access to the worldwide web however as with other cases that I am sure you are aware of that have been highlighted of late, my concern here is that some of the material Brad was exposed to was of a nature that a young person of his age should not be exposed to as they cannot, in my view, properly assimilate and process the information that they view. The amount of information on the subject of self-harm and suicide that is currently available to young persons on the internet goes beyond freedom of expression and I am concerned that the extent of such information Normalises actions which at the end of the day are simply not normal. It is not normal to self-harm and it is not normal to perform an act which results in that person’s own death.
I fully appreciate that the responsibility does not rest solely with Parliament, but the control of this entity has to start somewhere although I fully accept that to counter such activity will involve the combined efforts of Parliament, internet service providers, internet site owner, schools and colleges, parents/guardians as well as the young person’s themselves.
I can take judicial notice of when I was growing up that I do not recall ever discussing self-harm and suicide in the same way as it is discussed now, and I fear that the abundance of this type of information and the ease of its accessibility is leading to this concept of Normalisation of such actions . Yes, it is totally right that we should be open about mental health issues but the abundance of information that is out there on self-harming and suicide methods is a step too far hence my concern.
” 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 Publish the Online Harms White Paper setting out plans for legislation to improve companies’ responsibility for users’ online safety.
Verbatim wording from the response “That is why on 8 April we published our Online Harms White Paper (https://www.gov.uk/government/consultations/online-harms-white-paper) which sets out our plans for world-leading legislation to make the UK the safest place in the world to be online. This will make companies more responsible for their users’ safety online, especially children and other vulnerable groups.” Source location 2019-0207-Response-by-Department-for-Digital-Culture-Media-Sport
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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 Hold summits with social media providers addressing suicide and self-harm content on their platforms.
Verbatim wording from the response “The Secretary of State for Health and Social Care and the Minister for Mental Health, Inequalities and Suicide Prevention have also held two summits with social media providers this year about suicide and self-harm content on their platforms. Following these meetings, social media companies have committed to increasing their efforts to protect users by establishing, and funding, a strategic partnership with suicide and self-harm prevention experts, led by the Samaritans, to tackle this content and support vulnerable users of their platforms.” Source location 2019-0207-Response-by-Department-for-Digital-Culture-Media-Sport
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 Establish a statutory duty of care requiring companies to take greater responsibility for users’ safety online.
Verbatim wording from the response “The government will establish a new statutory duty of care to make companies take more responsibility for the safety of their users and tackle harm caused by content or activity on their services. Compliance with this duty of care will be overseen and enforced by an independent regulator. The regulator will set clear safety standards, backed up by mandatory reporting requirements and sufficient powers to take effective action against companies that breach regulatory requirements, including the power to levy substantial fines.” Source location 2019-0207-Response-by-Department-for-Digital-Culture-Media-Sport
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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 Production of online-harm codes of practice will be the new regulator’s responsibility once it becomes operational.
Verbatim wording from the response “Some of the areas we expect the regulator to include in a code of practice include:” Source location 2019-0207-Response-by-Department-for-Digital-Culture-Media-Sport
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Addressed to Department for Culture, Media and Sport, now represented here by Department for Digital, Culture, Media and Sport.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations