8 Sep 2025 Maureen Gilbert · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1 Lack of flood defences at Tapton Terrace View source
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Maureen Gilbert · 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
Maureen Gilbert, who was 83 years old, drowned in her home on 21 October 2023 after flood waters entered her property during Storm Babet. The report raises concern that the absence of flood defences at Tapton Terrace leaves residents, particularly those who may be elderly, vulnerable or immobile, at risk of life.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of flood defences at Tapton Terrace
Wider context from the report “Following the flood damage to Tapton Terrace in 2007, the Environment Agency’s pre-feasibility study identified a number of technically feasible options that would reduce the flood risk at Tapton Terrace. None of these measures were implemented principally due to cost reasons. When Storm Babet hit in October 2023, Tapton Terrace remained in the same position that it was in back in 2007. Due to the ongoing lack of flood defences, Tapton Terrace remains vulnerable to flooding. I am concerned that this gives rise to a risk to life, particularly in respect of residents who may be elderly, vulnerable or immobile.
” 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 Meet Derbyshire County Council and Environment Agency leaders to discuss flood protection in Chesterfield before winter.
Verbatim wording from the response “Moving forward from here, as Minister for Water and Flooding, I remain committed to helping increase the resilience of Tapton Terrace, Chesterfield and the whole country to flooding. Having met with Toby Perkins MP, I will also meet with Chris Henning (Executive Director at Derbyshire County Council) and Philip Duffy (Chief Executive at the Environment Agency) to discuss flood protection in Chesterfield ahead of this winter.” Source location Response from Department for Environment, Food & Rural Affairs
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How this respondent action was interpreted
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PFD Monitor interpretation Increase investment in flood-risk reduction.
Verbatim wording from the response “Flooding devastates communities. We take our responsibility in reducing these risks extremely seriously and we have acted to increase investment, change the rules around how funding for flooding is allocated and set up a Flood Resilience Taskforce to improve how prepared the country is for flooding.” Source location Response from Department for Environment, Food & Rural Affairs
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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 Change the rules governing allocation of flood-risk funding.
Verbatim wording from the response “Flooding devastates communities. We take our responsibility in reducing these risks extremely seriously and we have acted to increase investment, change the rules around how funding for flooding is allocated and set up a Flood Resilience Taskforce to improve how prepared the country is for flooding.” Source location Response from Department for Environment, Food & Rural Affairs
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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 Press the Environment Agency Chief Executive to undertake a Strategic Outline Case for Tapton Terrace in 2026.
Verbatim wording from the response “Taking into account the findings from your report, the fact that 18 years have passed since the last pre-feasibility study and with the introduction of new appraisal and funding rules, I agree with the Environment Agency’s conclusion that a new pre-feasibility study (which is now referred to as a Strategic Outline Case) should be taken forward and will underline to the Environment Agency’s Chief Executive, when we next meet, that this should be undertaken in 2026. As the Environment Agency’s response sets out, if a viable option is identified, it can then be considered for funding under the new, more straightforward funding rules, which take effect in April 2026.” Source location Response from Department for Environment, Food & Rural Affairs
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PFD Monitor interpretation Dredging the river channel at Tapton Terrace would not provide flood-risk benefit, based on the Environment Agency’s 2024 evidence.
Verbatim wording from the response “Dredging is one further option considered by the Environment Agency. Dredging and main river clearance is an important part of the Environment Agency’s wider annual programme of channel maintenance work. Before undertaking dredging, the Environment Agency works in close consultation with local communities to assess whether it is technically achievable, cost effective, and does not significantly increase flood risk for others downstream. The response from Environment Agency explains why, on the basis of evidence from 2024, they believe dredging the river channel at Tapton Terrace would not provide any flood risk benefit to the community.” Source location Response from Department for Environment, Food & Rural Affairs
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18 Jul 2025 David Joseph HAYES · Prevention of Future Deaths report Manchester West
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Concerns raised 4 Failure of washing detergent containers to restrict access by vulnerable adults or children View source Insufficient labelling warnings about risks to vulnerable adults and children View source Washing detergent packaging resembling items that vulnerable adults may confuse it with View source Lack of public awareness of the need to safeguard detergents from vulnerable adults View source See 1 more concern
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David Joseph HAYES · 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 HAYES, who had dementia, accidentally ingested washing detergent after confusing its packaging with a milk carton. He subsequently suffered vomiting, aspiration and pneumonitis, and died on 21 April 2025. The principal concerns were the detergent’s packaging and colouring, its accessible screw-top lid, and whether labelling and public awareness adequately addressed risks to vulnerable adults.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure of washing detergent containers to restrict access by vulnerable adults or children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient labelling warnings about risks to vulnerable adults and children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children .
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Washing detergent packaging resembling items that vulnerable adults may confuse it with
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of the need to safeguard detergents from vulnerable adults
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 Review detergents regulations with industry, considering legislative amendments and alternative measures to improve consumer safety.
Verbatim wording from the response “Whilst both regulatory and non-regulatory measures already exist to provide consumer protections, including for vulnerable people, Defra, working with colleagues across government as needed, will consider whether there are opportunities for improvements to these measures. In line with the UK government’s ‘new approach to ensure regulators and regulation support growth’, Defra aims to review our detergents regulations to consider whether any amendments are needed to improve our detergents regime. We will engage with the detergents industry to inform this work. In line with the Better Regulation Framework, whilst our policy review aims primarily to consider legislative changes, we will also consider alternative measures to regulation such as industry codes of conduct or standards that may be applicable.” Source location Response from Department for Environment, Food & Rural Affairs
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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 Defra does not enforce product safety regulations and directs relevant product information to local authority trading standards.
Verbatim wording from the response “GB product safety regulations require all consumer products to be safe when they are placed on the market. This includes regulations covering products that could be mistaken for food items and may cause harm if ingested, as noted above. There is not enough detailed information in your report to determine the extent to which products have complied with all the regulations noted above. Defra does not hold responsibility for enforcement of these regulations, but I have made the Office for Product Safety and Standards aware of this case. You may wish to consider passing any relevant information about the specific product in this case to the relevant local authority trading standards department.” Source location Response from Department for Environment, Food & Rural Affairs
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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 HSE considers legislative change unnecessary because there is no evidence that this case represents a widespread problem.
Verbatim wording from the response “Compliance with the requirements of GB CLP Regulation is enforced by various authorities covering a range of different supply contexts. Instances of non-compliance are subject to proportionate and pragmatic enforcement action which ensures that the risk of harm emanating from chemicals supplied in GB is minimised. There is no evidence to demonstrate that the circumstances of this case represent a more widespread problem and therefore HSE do not consider that changes to the legislation need to be considered at this time.” Source location Response from Department for Environment, Food & Rural Affairs
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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 Packaging design concerns requiring action must be considered under detergent-specific legislation, which is Defra’s responsibility, rather than CLP.
Verbatim wording from the response “The GB CLP Regulation, which is the responsibility of HSE, supports sector specific legislation. HSE have advised that any action deemed necessary to resolve the concerns raised in this case would need to be considered in relation to legislation specific to detergents, which supersedes the general legislative provisions of GB CLP. For example, for concern 6, CLP does not seek to identify or communicate risk factors (e.g. exposure to vulnerable adults).” Source location Response from Department for Environment, Food & Rural Affairs
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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 CLP-related concerns are HSE’s responsibility, so HSE provided the response rather than Defra.
Verbatim wording from the response “Thank you for your Regulation 28 report in relation to the death of David Joseph Hayes, dated July 18th 2025. Your report was addressed to the Secretary of State for Defra (being the Government department with responsibility for the regulation of Detergents). I am responding as the Deputy Director with responsibility for Chemicals, which includes Detergents policy and regulation. I have consulted with the Health and Safety Executive (HSE) as some of the issues raised fall within their remit as a regulator for the supply of chemicals in Great Britain (GB). Specifically in reference in this response, HSE have responsibility for Classification, Labelling and Packaging (CLP) regulations so they and not Defra have provided the text for the response in relation to this area.” Source location Response from Department for Environment, Food & Rural Affairs
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7 Feb 2025 Carla James · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Failure to provide warnings about highly poisonous and toxic products that can endanger life View source
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Carla James · 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
Carla James died unexpectedly at her home address in Tottington, Bury, on 18 August 2024, aged 50. Evidence at the scene indicated she may have ingested material from a plant. The report raises concern that highly poisonous and toxic products were being imported and sold nationally without warnings that they could endanger life.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to provide warnings about highly poisonous and toxic products that can endanger life
Wider context from the report “████████ are being imported and sold nationally with no warnings as to the fact they are highly poisonous and toxic and can endanger life .
” Open source report
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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 Office for Product Safety and Standards is examining the issue and is expected to respond to the coroner.
Verbatim wording from the response “Given this, my officials have been in touch with the Department for Business and Trade (DBT). We understand this issue is being examined by the Office for Product Safety and Standards and that they intend to write to you. It goes without saying that Defra will support the work of DBT in any way we can.” Source location Response from Department for Environment, Food and Rural Affairs
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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 Legislative powers do not permit requiring health warnings for potentially hazardous plants and plant products imported into Great Britain.
Verbatim wording from the response “Defra is responsible for trade in regulated plants and plant material including seeds for planting. This includes responsibility for the intellectual property rights of plant breeders, plant variety registration and setting standards for marketing and certification of seed for planting and other regulated plant material. However, Defra does not have legislative powers to require health warnings, or similar, to be included when potentially hazardous plants and plant products are imported into GB.” Source location Response from Department for Environment, Food and Rural Affairs
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21 Apr 2023 Names not published · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Lack of a physical barrier preventing access to the hazardous bottom of the weir View source
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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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Names not published · 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
Two women were found in the River Great Ouse at Kempston Mill on 16 April 2023 after renting canoes, and both were pronounced dead at the scene. The report identifies concern that, although there was a barrier at the top of the weir, there was no similar barrier at the hazardous bottom where recirculating flow was present, particularly during high water levels.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of a physical barrier preventing access to the hazardous bottom of the weir
Wider context from the report “Although there is a physical barrier to prevent access to the top of the weir, there is no similar barrier to prevent access to the bottom which appears just as hazardous in view of the re-circulating flow (or towback), particularly during time of high water levels .
” Open source report
20 Jan 2023 Michael John Holmes · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Lack of expertise to assess and control cattle trampling risks on small farms View source Unclear requirements for bringing dogs onto public footpaths near cattle View source Unpredictable aggressive cattle reactions to dogs in fields View source Insufficient oversight and management of public rights of way near grazing cattle View source Cattle trampling hazard when walkers with dogs encounter cows with calves View source Failure to separate walkers from cattle on rights of way View source See 3 more concerns
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Michael John Holmes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Holmes died after being knocked down and trampled by cattle while walking dogs with his wife on a public footpath through a field. The report raised concerns about the risks of walkers, particularly those accompanied by dogs, coming into contact with cattle and calves, and about the management and separation of public footpaths from grazing cattle.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of expertise to assess and control cattle trampling risks on small farms
Wider context from the report “4.1. The current potential for a hazard to be created by walkers on public footpaths moving in proximity to a farmer’s grazing cattle, requires management of these competing interests. It was contended at the inquest that the farmer is subject to a statutory duty to carry out a risk assessment in accordance with the Management of Health & Safety at Work Regulations 1999. It was contended that a landowner must conduct his business around the existing public footpath, irrespective of which came into existence first. Whilst not disputing the legal duty imposed on a farmer in these circumstances, the potential mischief left unguarded in that analysis, is that Small & Medium Enterprises (SME’s) such as small family farms may lack the expertise to recognise the problem, carry out an effective risk assessment in relation to cattle trampling risks and devise reasonably practicable control measures.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Unclear requirements for bringing dogs onto public footpaths near cattle
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs. Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Unpredictable aggressive cattle reactions to dogs in fields
Wider context from the report “3.1. It is difficult to predict whether a particular cow will react aggressively to the presence of a dog in a field. It was suggested during the inquest, the risk of such a reaction is highest in the months after the birth of a calf.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient oversight and management of public rights of way near grazing cattle
Wider context from the report “4.2. To avoid the harm envisaged by further deaths in comparable circumstances, the HSE and Local Authorities should explore ways to apply their expertise in collaboration with landowners (of the type involved in this inquest), whether on a paid or voluntary basis. The maintenance of safe public rights of way could be said to require oversight and management by public bodies as well as the landowners concerned
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Cattle trampling hazard when walkers with dogs encounter cows with calves
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs . Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to separate walkers from cattle on rights of way
Wider context from the report “1.2. Statistics from the Health & Safety Executive (‘HSE’) indicate that on average 6 people have died each year from injuries sustained in cattle trampling incidents. 11 people died in 2020, one of whom was Mr Holmes. Such incidents are avoidable if walkers and cattle are separated. In my judgment, this unacceptable situation necessitates a review of the arrangements in which walkers are brought into contact with cows and their calves, by virtue of rights of way .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review how to make guidance on diverting public rights of way more accessible as part of the rights of way reforms.
Verbatim wording from the response “Defra and its statutory adviser, Natural England, are responsible for setting out the legislation framework and producing guidance for the management of the public rights of way network. Guidance is already available for the diverting of public rights of way in accordance with the Highways Act 1980 however as part of the rights of way reforms package we are taking forward we will look at how we can make this more accessible.” Source location Response from DEFRA
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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 Implement rights of way reforms granting landowners a statutory right to apply for permanent footpath or bridleway extinguishment or diversion orders in the public interest.
Verbatim wording from the response “However, we are committed to implementing a number of rights of way reforms which include giving landowners the statutory right to apply to a local authority for a public path order to permanently extinguish or divert a footpath or bridleway where it is in the public interest to do so.” Source location Response from DEFRA
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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 Health and Safety Executive is responsible for guidance on livestock risks to farmers, landowners and other livestock keepers.
Verbatim wording from the response “Defra is responsible for rights of way policy and this response sets out Defra’s response to the points you have addressed to this department. I note that you have also copied your report to the Health and Safety Executive who have responded to you separately in light of their responsibilities for providing guidance to farmers, landowners and other livestock keepers about the assessment of risks posed by livestock being kept in a field with a public right of way.” Source location Response from DEFRA
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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 There are currently no plans to introduce regulations enabling temporary public right of way diversion orders.
Verbatim wording from the response “We are aware of calls for a change in legislation to enable temporary path diversion orders however there are no plans to introduce such regulations at this time.” Source location Response from DEFRA
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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 Planning Inspectorate will decide the public right of way diversion application on behalf of the Secretary of State.
Verbatim wording from the response “As you pointed out in your report, objections to the diversion have been received therefore an application has been made to the Planning Inspectorate which is currently processing the application and will consider carefully any representations and objections received in accordance with standard procedures before making a decision on behalf of the Secretary of State.” Source location Response from DEFRA
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
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Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Fund research and pilot studies into low-cost air-quality sensors.
Verbatim wording from the response “35. As part of this process, in 2018/19 Defra commissioned the Environment Agency to carry out a strategic review of the monitoring network, including external engagement with end users and experts. It has secured £1M for this year (2021/2022) and initiated an expansion of particulates monitoring networks. Defra has also funded research and development and practical pilot studies into the use of new low-cost sensor technology (£2m over the last two years). In order to identify suitable technical standards for measurement of accuracy and other performance parameters (which is currently a significant barrier for the use of low-cost sensor technology), Defra is working with the British Standards Institute and the National Physics Laboratory and intends to commission the development of a Publicly Available Specification in the Summer.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Undertake a fundamental review of the UK-AIR website to improve functionality, user experience and information dissemination.
Verbatim wording from the response “41. Defra’s User Needs research¹⁵ has highlighted that those searching for air quality information can often find it complex and difficult to interpret. The CDGs are committed to improving the provision of air quality data and information. In order to do this, the following actions are being taken forward:” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Increase Air Quality Grant funding for local authorities to £8 million.
Verbatim wording from the response “d) This year, Defra is increasing the amount of Air Quality Grant funding available for Local Authorities to £8million. We will invite specific proposals to use a proportion of this funding to enhance local air quality information and awareness, encouraging local health networks to work collaboratively with Local Authorities to pilot more effective methods of public engagement.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Commission development of a publicly available specification for low-cost air-quality sensors.
Verbatim wording from the response “35. As part of this process, in 2018/19 Defra commissioned the Environment Agency to carry out a strategic review of the monitoring network, including external engagement with end users and experts. It has secured £1M for this year (2021/2022) and initiated an expansion of particulates monitoring networks. Defra has also funded research and development and practical pilot studies into the use of new low-cost sensor technology (£2m over the last two years). In order to identify suitable technical standards for measurement of accuracy and other performance parameters (which is currently a significant barrier for the use of low-cost sensor technology), Defra is working with the British Standards Institute and the National Physics Laboratory and intends to commission the development of a Publicly Available Specification in the Summer.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Design an expanded air-quality monitoring framework to measure population exposure and evaluate policy effectiveness.
Verbatim wording from the response “34. In setting new targets through the Environment Bill, there is also a commitment to significantly enhancing the monitoring network, with a view to capturing population wide exposure, as well as supplemental monitoring in order to enhance its ability to assess progress and evaluate the effectiveness of policy interventions. The work to design an expanded monitoring framework is to be undertaken alongside the ascertainment of targets set out above.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Set annual PM2.5 concentration and population-exposure reduction targets through the Environment Bill.
Verbatim wording from the response “5. The CGDs note the Coroner’s concern that the UK’s current national limits for particulate matter concentrations are higher than the guidelines set by the WHO. The CGDs accept that there is more work to be done at the national level to reduce overall concentrations of particulate matter. The Environment Bill currently making its way through Parliament will make provision for the introduction of a) an annual mean concentration target for PM₂.₅ in ambient air; and b) a population exposure reduction target for PM₂.₅. An extensive public consultation is being planned to take place over the course of the next year.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Expand particulate-matter monitoring networks using secured funding.
Verbatim wording from the response “35. As part of this process, in 2018/19 Defra commissioned the Environment Agency to carry out a strategic review of the monitoring network, including external engagement with end users and experts. It has secured £1M for this year (2021/2022) and initiated an expansion of particulates monitoring networks. Defra has also funded research and development and practical pilot studies into the use of new low-cost sensor technology (£2m over the last two years). In order to identify suitable technical standards for measurement of accuracy and other performance parameters (which is currently a significant barrier for the use of low-cost sensor technology), Defra is working with the British Standards Institute and the National Physics Laboratory and intends to commission the development of a Publicly Available Specification in the Summer.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 conduct a public consultation on proposed air-quality targets, including evidence, achievability, interventions, costs and health benefits.
Verbatim wording from the response “5. The CGDs note the Coroner’s concern that the UK’s current national limits for particulate matter concentrations are higher than the guidelines set by the WHO. The CGDs accept that there is more work to be done at the national level to reduce overall concentrations of particulate matter. The Environment Bill currently making its way through Parliament will make provision for the introduction of a) an annual mean concentration target for PM₂.₅ in ambient air; and b) a population exposure reduction target for PM₂.₅. An extensive public consultation is being planned to take place over the course of the next year.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Invite local-authority proposals to improve air-quality information, awareness and public engagement.
Verbatim wording from the response “d) This year, Defra is increasing the amount of Air Quality Grant funding available for Local Authorities to £8million. We will invite specific proposals to use a proportion of this funding to enhance local air quality information and awareness, encouraging local health networks to work collaboratively with Local Authorities to pilot more effective methods of public engagement.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Work with standards bodies to establish technical standards for low-cost sensor accuracy and performance.
Verbatim wording from the response “35. As part of this process, in 2018/19 Defra commissioned the Environment Agency to carry out a strategic review of the monitoring network, including external engagement with end users and experts. It has secured £1M for this year (2021/2022) and initiated an expansion of particulates monitoring networks. Defra has also funded research and development and practical pilot studies into the use of new low-cost sensor technology (£2m over the last two years). In order to identify suitable technical standards for measurement of accuracy and other performance parameters (which is currently a significant barrier for the use of low-cost sensor technology), Defra is working with the British Standards Institute and the National Physics Laboratory and intends to commission the development of a Publicly Available Specification in the Summer.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Undertake further work with general practitioners to provide air-quality advice and information to vulnerable groups.
Verbatim wording from the response “49. Another example of the work being undertaken is a Defra funded pilot project, conducted by Global Action Plan and the UK Health Alliance on Climate Change, investigating whether and how respiratory physicians and paediatricians could be trained to better deliver air quality advice to their patients, and act as champions for air quality within their places of work. Defra are keen to build on this work and are planning further work with general practitioners providing air quality advice and information to a range of vulnerable groups.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 Achieving WHO particulate-matter guideline levels everywhere may not be technically or socio-economically feasible, particularly in densely populated urban areas.
Verbatim wording from the response “14. As recognised in the 2005 update the extent to which reductions in small particle concentrations to or below the guideline levels recommended by the WHO are technically feasible will vary from country to country and will depend on local circumstances.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
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 WHO air-quality guidelines are not standards requiring direct adoption; national limits may reflect local health, feasibility, economic and social considerations.
Verbatim wording from the response “management and environmental policies. National standards will vary according to the approach adopted for balancing health risks, technological feasibility, economic considerations and various other political and social factors, which in turn will depend on, among other things, the level of development and national capability in air quality management. The guideline values recommended by WHO acknowledge this heterogeneity and, in particular, recognize that when formulating policy targets, governments should consider their own local circumstances carefully before adopting the guidelines directly as legally based standards.” Source location 2021-0113-Response-from-Central-Government-Departments-DEFRA-DFT-and-DHSC-Redacted
Open published response
Concerns raised 7 Risk of serious injury or death to the public on public bridleways on or adjacent to working farms View source Unavailability of a usable secure gate at the entrance to the bridleway View source Lack of specific planning for the heightened risks of young calves during first release from winter shed View source Lack of formal cattle movement plans View source Lack of contingency plans for cattle breakout View source Failure to warn the public of impending cattle movement and its risks View source Failure to secure cattle in the holding area before movement 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
Marian Elizabeth CLODE · 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
Marian Elizabeth Clode was attacked three times by a cow while walking with her family on a public bridleway near Swinhoe Farm on 3 April 2016, and died from the resulting injuries on 5 April 2016. The concerns included cattle movements without formal or contingency plans, inadequate measures to prevent cattle breaking out, and no warning to the public about the cattle movement and associated 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Risk of serious injury or death to the public on public bridleways on or adjacent to working farms
Wider context from the report “(1) There is a continuing risk to the public of serious injury or death in exercising their right to walk on public bridleways on or adjacent to working farms.
(2) A robust system of Regulation of farming practice in the context of Public Rights of way and guidance to the public is necessary to mitigate that risk.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a usable secure gate at the entrance to the bridleway
Wider context from the report “(3) Secure gate at the entrance to bridle way unable to be utilised due to direction of opening which with some limited alteration may have gone someway to mitigate the risk in this case.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of specific planning for the heightened risks of young calves during first release from winter shed
Wider context from the report “(1) Cattle movement being commonly undertaken in accordance with individual farmers “custom and practice” and in the absence of:
a) formal plans for cattle movement (written or verbal)
b) Contingency plans/strategies in the event of cattle breakout
c) Specific planning in respect of the heightened risk associated with the presence of young calves and in the context of their first release from winter shed
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of formal cattle movement plans
Wider context from the report “(1) Cattle movement being commonly undertaken in accordance with individual farmers “custom and practice” and in the absence of:
a) formal plans for cattle movement (written or verbal)
b) Contingency plans/strategies in the event of cattle breakout
c) Specific planning in respect of the heightened risk associated with the presence of young calves and in the context of their first release from winter shed
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency plans for cattle breakout
Wider context from the report “(1) Cattle movement being commonly undertaken in accordance with individual farmers “custom and practice” and in the absence of:
a) formal plans for cattle movement (written or verbal)
b) Contingency plans/strategies in the event of cattle breakout
c) Specific planning in respect of the heightened risk associated with the presence of young calves and in the context of their first release from winter shed
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to warn the public of impending cattle movement and its risks
Wider context from the report “(2) Cattle movement undertaken without appropriate measures in place to mitigate the risks of cattle breakout:
a) Cattle held prior to movement in a holding area pen which was insecure. Cattle contained only by quad bike and trailer (driven by farmer) at the front of the herd.
b) No warning to the public of impending cattle movement and the risks thereof either by temporary warning signage or farm staff place at strategic points on the planned route to give verbal warning.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to secure cattle in the holding area before movement
Wider context from the report “(2) Cattle movement undertaken without appropriate measures in place to mitigate the risks of cattle breakout:
a) Cattle held prior to movement in a holding area pen which was insecure. Cattle contained only by quad bike and trailer (driven by farmer) at the front of the herd.
b) No warning to the public of impending cattle movement and the risks thereof either by temporary warning signage or farm staff place at strategic points on the planned route to give verbal warning.
” 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 Implement Right to Apply provisions enabling landowners to apply to local authorities to extinguish or divert public rights of way, with a right of appeal.
Verbatim wording from the response “Defra are undertaking a package of reforms to the rights of way system which will lead to improvements in various areas, including an improved capacity for landowners to move certain rights of way on their land. Under provisions known as the ‘Right to Apply’, landowners will now be able to make formal applications to local authorities to extinguish or divert rights of way from their land with a right of appeal to the Secretary of State if the authority refuses or fails to respond. These applications will be considered on a case by case basis and the outcomes cannot be guaranteed. Guidance will however encourage local authorities to remove public rights of way wherever possible from premises where privacy, safety and security are of a significant concern, including family gardens and working farmyards.” Source location 2021-0228-Response-from-DEFRA-Redacted
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 Issue guidance encouraging local authorities to remove public rights of way from premises where privacy, safety or security is a significant concern.
Verbatim wording from the response “Defra are undertaking a package of reforms to the rights of way system which will lead to improvements in various areas, including an improved capacity for landowners to move certain rights of way on their land. Under provisions known as the ‘Right to Apply’, landowners will now be able to make formal applications to local authorities to extinguish or divert rights of way from their land with a right of appeal to the Secretary of State if the authority refuses or fails to respond. These applications will be considered on a case by case basis and the outcomes cannot be guaranteed. Guidance will however encourage local authorities to remove public rights of way wherever possible from premises where privacy, safety and security are of a significant concern, including family gardens and working farmyards.” Source location 2021-0228-Response-from-DEFRA-Redacted
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 HSE is the enforcing authority responsible for incidents involving cattle on farms.
Verbatim wording from the response “We have discussed the details of this specific case with the Health and Safety Executive (HSE), Britain’s national regulator for workplace health and safety. HSE is the enforcing authority for incidents involving cattle on farms. HSE are already aware of this case and have provided the below information relevant to this situation. An overview of HSE procedures is published online:” Source location 2021-0228-Response-from-DEFRA-Redacted
Open published response
30 Sep 2019 Owen Carey · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of statutory requirements for the appearance of restaurant allergen notices View source Lack of complete allergen information on the face of restaurant menus View source Lack of a national register of severe food anaphylactic reactions View source Inadequate allergen training for serving staff View source Insufficient prominence of allergen notices on restaurant menus 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
Owen Carey · 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 22 April 2017, Owen Carey ate food at Byron restaurant at the O2 centre despite making serving staff aware of his dairy allergy. The chicken contained buttermilk, causing a severe food-induced anaphylactic reaction from which he died. Concerns included the adequacy of allergen training, the prominence and effectiveness of allergen notices and information on menus, and the absence of a national register for severe food anaphylactic reactions.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory requirements for the appearance of restaurant allergen notices
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of complete allergen information on the face of restaurant menus
Wider context from the report “(3) The lack of key allergen information on the face of restaurant menus and therefore their potential to be falsely reassuring: In my findings I concluded that Owen and his brother would have been falsely reassured with the menu description of Owen's order because on its face the Byron O2 menu in place at the time did not readily identify that the chicken would have been marinated in buttermilk or at all. I was shown a more up to date menu from Byron O2 and note that where buttermilk is now used to marinate chicken it is identified. However, the prompt for this change was one of ‘food fashion’ I was told rather than a move to make the menu more allergen friendly. Although I accept that triggering a discussion between a customer and member of serving staff about allergens is of key importance (as indicated above), the absence of any simple allergen words or symbols on the face of a restaurant menu is of concern , particularly when one takes into account (i) what I was told about the latest figures demonstrating how a significant proportion of customers may be naturally shy/ reluctant about sharing their allergies with serving staff and (ii) that restaurants, like Byron O2, tend to attract younger diners dining alone (i.e. school age children without their parents). It also concerns me that at the time there were symbols on the menu depicting the use of peanuts, but not other allergen , which in my view could also have potentially falsely reassured diners that allergens were being identified on the face of the menu when in fact they were not .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of a national register of severe food anaphylactic reactions
Wider context from the report “(4) The lack of a national register recording severe food anaphylactic reactions: I was told in evidence that despite faster ambulance response times, a greater awareness of allergies and a greater distribution of epi-pens that the death rate for severe food anaphylaxis remains static and that this is attributed in part to the fact that little is known about these deaths because thus far there has been a failure to collect together any learning from these tragedies . It concerns me that there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Inadequate allergen training for serving staff
Wider context from the report “(1) The adequacy and effectiveness of allergen training at Byron O2: My findings included that there must have been a human error by a member of Byron O2 serving staff at the point of ordering. The training provided to serving staff regarding allergens at Byron O2 was limited to a combination of staff members simply attesting to the fact that they had read the company's training on allergen information and no more, coupled with an “on the job” induction in respect of which no records or details existed. It was accepted in evidence that Byron O2 had a high turnover of serving staff. This, I was told and accept, is common for the restaurant industry overall, who often rely, for example on seasonal workers. I was not confident that the current approach to allergen training about which I heard evidence was effective and / or would engage the less diligent employee , which any organisation will have, and which are potentially in a greater proportion where there is high staff turnover.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient prominence of allergen notices on restaurant menus
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” 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 Research how businesses and consumers understand, communicate and use allergen information to inform further guidance updates.
Verbatim wording from the response “requirements remain clear, including the requirement for notices (on menus and elsewhere) to be readily discernible. We want to be sure that businesses are communicating allergen information to consumers in the most effective ways, and we are currently undertaking further research into how businesses understand and act on their responsibilities and how consumers receive and use this information. This research will inform any further updates to business guidance.” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
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 Increase information about deaths from anaphylactic reactions by identifying access to relevant records for inclusion in the planned reporting platform and analysis.
Verbatim wording from the response “The Department of Health and Social Care (DHSC) notes the recommendation on a fatalities register and concurs that it is essential we learn from these tragedies. In conjunction with the FSA’s ongoing programme to collect more information on anaphylactic reactions, DHSC will work to increase information prevalence on these deaths. The Department will identify means of access to relevant records so that they may be included, as is necessary and appropriate in preventing future incidents, within the FSA’s planned reporting platform and purposes of analysis. In addition to this the Department wishes to underline its emphatic support of the FSA’s strategy on food hypersensitivity.” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
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 Investigate a reporting platform and related data-sharing arrangements for allergic reactions, including severe non-fatal reactions.
Verbatim wording from the response “The FSA agrees that there needs to be more systematic information collected on anaphylactic reactions, and that the evidence base is currently inadequate. The FSA is exploring how to collect more data on allergic reactions so that we and others can identify emerging patterns or trends and build a better picture of allergic consumer experience of reactions. We have therefore embarked on work investigating a reporting platform for allergic reactions, including better information on severe reactions that do not result in a death. This is in the early stages as it is likely to involve the development of an online reporting system and/or better data sharing and exchange of information between different organisations.” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
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 Update business guidance to clarify effective allergen information and readily discernible notices.
Verbatim wording from the response “Regardless of the method chosen, the information must be accurate and up-to-date. We are currently updating our guidance for businesses and will ensure that these” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
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 Food businesses bear primary legal responsibility for ensuring food safety and providing accurate allergen information.
Verbatim wording from the response “The overarching responsibility of food business operators is set out in Regulation (EC) No. 178/2002 (‘The EU General Food Law’), Article 17(1): Food and feed business operators at all stages of production, processing and distribution within the businesses under their control shall ensure that foods or feeds satisfy the requirements of food law which are relevant to their activities and shall verify that such requirements are met. The reasoning for this is provided in Recital (30) in that a food business operator is best placed to devise a safe system for supplying food and ensuring that the food it supplies is safe; thus, it should have primary legal responsibility for ensuring food safety. Of course, food law places responsibilities on both operators and food businesses through other general and specific requirements too, and such is the case with the provision of allergy information.” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
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 Local authorities are responsible for assessing restaurant allergen compliance and taking corrective or enforcement action where necessary.
Verbatim wording from the response “Local authorities have responsibility for assessing how businesses, such as Byron, comply with food law and will take corrective action where any issues are identified. In carrying out their duties, local authorities will assess levels of compliance, including in relation to allergen management, through inspections, record and traceability checks, food sampling and staff interviews. Where non-compliance is identified, local authorities will work with the business to improve standards and take appropriate, proportionate enforcement action should that be necessary. The FSA has responsibility for oversight of this work and the Food Law Code of Practice is the primary mechanism through which the FSA gives direction to local authorities to ensure a degree of consistency in approach.” Source location 2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
Open published response
23 Sep 2019 Kristiyan Petrov Danailov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of industry awareness of risks when dealing with customers over the internet View source Insufficient safeguards against vulnerable individuals purchasing hazardous items View source Insufficient identity checks before postal dispatch of hazardous items 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
Kristiyan Petrov Danailov · 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
Kristiyan Petrov Danailov was found unresponsive at home on 28 July 2018 after purchasing an online product labelled as containing cyanide, and was pronounced deceased at the scene. The inquest concluded that the death was suicide, with the medical cause recorded as consistent with cyanide poisoning. Concerns were raised about checks on the identity and vulnerability of customers purchasing hazardous items online and about industry awareness of the 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of industry awareness of risks when dealing with customers over the internet
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post. What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient safeguards against vulnerable individuals purchasing hazardous items
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post. What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient identity checks before postal dispatch of hazardous items
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post . What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet.
” Open source report
Concerns raised 10 Inadequate tiger-enclosure entry method statement and risk assessment View source Insufficiently clear and prescriptive guidance on double gates for tiger enclosures View source Over-reliance on individual keeper reliability as the tiger-enclosure entry control View source Lack of clear guidance requiring licensed conventional firearms at zoos holding tigers View source Absence of double keeper gates to tiger paddocks View source Inadequate fatigue-risk controls for keepers undertaking night-time hand-rearing View source Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems View source Insufficient trained firearms staff to provide continuous zoo cover View source Failure to complete approval, secure storage and acquisition of conventional firearms View source Lack of access to conventional firearms for escaped or uncontrolled tigers View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Publish the revised zoo standards and associated licensing documentation, inspection reports, and statutory guidance by the end of 2020.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2019. View source
Action
Launch consultation on the revised zoo standards and associated licensing documentation, inspection reports, and statutory guidance.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2019. View source
Action
Develop revised zoo standards with legally enforceable obligations, expert engagement, and integration into zoo inspection reporting.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 September 2019. View source
Action
Provide nominated Secretary of State inspectors with training on the new firearms and double-door requirements before the new Standards take effect.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2019. View source
Action
Update standard zoo inspection report templates to reflect the new firearms, double-door, safe-system-of-work and training requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2019. View source
Action
Consulted stakeholders, developed and published new Standards requiring stronger controls for hazardous-animal firearms, enclosure access, safe systems of work and lone working.
Stated completedThe respondent said that this action was complete when they made their response on 18 September 2019. View source See 3 more actions
×
AI-generated summary
ROSA ANN KING · 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
Rosa Ann King, a senior carnivore keeper at Hamerton Zoological Park, died on 29 May 2017 after being attacked by a Malayan tiger while exiting the tiger paddock. She had entered while the tiger slides were open, and the report identified concerns about reliance on keeper reliability, fatigue from night-time hand-rearing work, the absence of air-lock type double gates, and lack of access to conventional firearms. The report also raised concerns about insufficient guidance, risk assessment and inspection of these safety arrangements.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Inadequate tiger-enclosure entry method statement and risk assessment
Wider context from the report “5.4.2 I heard evidence that Hamerton zoo’s “Review of Tiger Protocols” was not a suitable method statement for working in the tiger enclosures . It did not explicitly set out every necessary stage of checks in the system for entering a tiger area ; it had not been updated; it addressed only some of the tasks that were required (for example, it did not address entry into the Tiger paddock where Rosa was attacked). I heard evidence that the relevant risk assessment was not suitable ; that it did not consider the risk of human failure , and did not address the risk of a member of staff omitting a critical check or action due to an unintentional slip, lapse or mistake, or an intentional violation.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear and prescriptive guidance on double gates for tiger enclosures
Wider context from the report “5.2.6 I am concerned that:
• Hamerton Zoo was able to pass previous ZLA inspections without any recommendation being made that a double keeper gate be fitted to its tiger enclosures.
• The DEFRA guidance by inclusion of the words, “In general …” is insufficiently clear and insufficiently prescriptive on the standards that should apply to an enclosure holding animals as deadly as tigers. Similar considerations apply to the HSE guidance.
The fact that other zoos may not have double keeper gates fitted to tiger enclosures, and the lack of more prescriptive guidance , carry a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on individual keeper reliability as the tiger-enclosure entry control
Wider context from the report “5.4.1 The system for entering the tiger enclosures at Hamerton zoo was simple, and involved a number of visual checks by the tiger keeper. However, as found by the jury, I heard evidence that this system was totally dependent on the keepers reliably following their training . There was no further control measure (whether involving engineering design, a flag or sign system, CCTV, the use of radio checks or otherwise) to limit the human error risk. I heard expert evidence that training on its own is not an effective measure to reduce the risks of slips, lapses or violations. I heard evidence that in relation to a task which carries the risk of single or multiple fatalities, human actions should not be relied on to be the control of the hazard unless as a final resort.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance requiring licensed conventional firearms at zoos holding tigers
Wider context from the report “5.1.4 I heard evidence that DEFRA’s “Secretary of State’s Standards of Modern Zoo Practice” is being redrafted/has been redrafted but is not yet published. Paragraph 8.20 of the guidance as currently drafted states,
“Where a zoo holds any primate, carnivore, elephant, or hoofed mammal listed in category 1 of Appendix 12, appropriate firearms must be available, unless a risk assessment has shown that a firearm would not provide the most appropriate means of protection to the public from that animal, and other arrangements have been made.”
I am concerned that the wording of this provision may have contributed to the zoo being able to pass ZLA inspections since it held one form of firearm (a dart gun) and had an arrangement with local police for conventional firearms cover. In contrast, I received evidence from an independent expert and highly experienced zoo manager, designer and consultant that he was “stunned to learn that no firearms were kept on site at Hamerton and they had had tigers since around 2003”. I am concerned that a lack of clear guidance that all zoos which hold tigers must possess licensed conventional firearms carries a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Absence of double keeper gates to tiger paddocks
Wider context from the report “5.2.1 I am concerned that, some time, error on the part of a safety-conscious experienced zoo keeper led to a situation whereby a tiger could have attacked multiple members of the visiting public. Double keeper gates to the tiger paddock would very likely have prevented this risk. They were not fitted at the time.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Inadequate fatigue-risk controls for keepers undertaking night-time hand-rearing
Wider context from the report “5.3.2 I heard evidence that since Rosa’s death, the zoo has introduced a formal policy for the hand-rearing of animals. That policy (which on its face was meant to have been reviewed on 24 April 2019) reduces, but does not eliminate, my concerns in this regard. It provides that the period of consecutive days staff spent hand-rearing should be “kept to a minimum”. However, it goes on to provide that this is to be, “at the staff members own discretion” after what is said to be “self-evaluation” . For hand-rearing done at home, the work remains viewed as voluntary and unpaid. The policy does not make provision for the hours spent in such activity to be monitored for safety reasons , although in a document provided on the last day of the inquest, I was told that this would be introduced before any further hand-rearing was done. The policy does not make any separate provision or safeguards for those keepers whose day jobs involve them working with the highest risk animals like tigers , where there is a risk of fatalities if fatigue-induced mistakes are made. No advice had been taken from any outside expert on the safety implications of night-working or the patterns of work being undertaken . I am concerned that there remains a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems
Wider context from the report “5.4.6 In light of the aforesaid, I am concerned that there is an ongoing risk nationally that systems for entering tiger enclosures may be entirely dependent or overly-dependent on the reliability of individual zoo keepers without sufficient account being taken of the risk of human failures . Further, such risks may not be effectively addressed by zoo inspections nor sufficiently publicised in DEFRA and HSE guidance . This carries a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Insufficient trained firearms staff to provide continuous zoo cover
Wider context from the report “5.1.3. Moreover, at present only two members of the zoo staff have been trained to use conventional firearms . I am concerned that this is too few a number to ensure that a member of staff trained in conventional firearms will always be on duty when the public have admittance to the zoo . This carries a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to complete approval, secure storage and acquisition of conventional firearms
Wider context from the report “5.1.2 I heard evidence that the zoo has taken measures for two members of staff to obtain firearms’ licences and they have received firearms training. However, I heard evidence that the zoo has not yet been approved as premises to hold firearms (action for which rests with the firearms licensing department at the local constabulary) and the zoo has not yet fitted appropriate firearm secure containers . While moving to hold conventional firearms has been made a condition of the zoo’s licence under the Zoo Licensing Act 1981 (ZLA), I am concerned that more than two years after Rosa’s death, the process of the zoo obtaining conventional firearms has still not been completed . This carries a risk of further 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of access to conventional firearms for escaped or uncontrolled tigers
Wider context from the report “5.1.1. Should a tiger escape from the tiger enclosures at Hamerton Zoo or a keeper should inadvertently find themselves in the same area as a tiger, I am concerned that the zoo still does not currently have access to conventional firearms to shoot a tiger in that situation to preserve human life .
” 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 Publish the revised zoo standards and associated licensing documentation, inspection reports, and statutory guidance by the end of 2020.
Verbatim wording from the response “To allow for the above, we now expect that the consultation on the revised SSSMZP and associated licensing documentation, including the inspection reports and the Guide to the Zoo Licensing Act 1981, will be launched over the summer and publication will take place no later than the end of 2020.” Source location Response from DEFRA
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 Launch consultation on the revised zoo standards and associated licensing documentation, inspection reports, and statutory guidance.
Verbatim wording from the response “To allow for the above, we now expect that the consultation on the revised SSSMZP and associated licensing documentation, including the inspection reports and the Guide to the Zoo Licensing Act 1981, will be launched over the summer and publication will take place no later than the end of 2020.” Source location Response from DEFRA
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 revised zoo standards with legally enforceable obligations, expert engagement, and integration into zoo inspection reporting.
Verbatim wording from the response “Defra is committed to addressing the issues raised in the Regulation 28 report by creating a robust set of standards which place clear, legally enforceable obligations on zoos, and which are reflected in the zoo inspection reporting process. As set out in our response, the SSSMZP are developed by working closely with the Zoos Expert Committee (ZEC), an advisory body whose purpose is to provide independent, impartial and expert advice to Defra. Defra is working at pace in order to have the new set of standards published by the timescale. However, Defra has been advised strongly by ZEC to allow more time to engage fully with a wider range of experts to ensure that the new SSSMZP meet the intended objectives of securing public safety and improving animal welfare.” Source location Response from DEFRA
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 Provide nominated Secretary of State inspectors with training on the new firearms and double-door requirements before the new Standards take effect.
Verbatim wording from the response “Before the new Standards come into force, Defra will also be providing training to those inspectors nominated by the Secretary of State to ensure they are familiar with the new firearms requirements.” Source location Response from DEFRA (Update July 2025)
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 Update standard zoo inspection report templates to reflect the new firearms, double-door, safe-system-of-work and training requirements.
Verbatim wording from the response “Defra will now ensure that the standard zoo inspection report templates are updated in line with the requirements in the new Standards as set out in point (6.2) above. During the inspection process the inspector will be expected to confirm that zoos with any Category 1A or Category 1 listed primate, terrestrial member of the order Carnivora, elephant or hoofed mammal have suitable and sufficient firearms and ammunition, appropriate for the species housed, kept on the zoo premises for use by authorised staff, and that at least one member of staff who is licensed and trained in the use of firearms is available on the zoo premises during operational hours and is able to attend the premises within 20 minutes outside of operational hours.” Source location Response from DEFRA (Update July 2025)
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 Consulted stakeholders, developed and published new Standards requiring stronger controls for hazardous-animal firearms, enclosure access, safe systems of work and lone working.
Verbatim wording from the response “I can confirm that between 1 March 2022 and 21 June 2022 Defra undertook a targeted consultation on draft new Standards of Modern Zoo Practice for Great Britain (hereafter the ‘new Standards’). Defra consulted zoos, animal keepers, welfare groups, local authorities and worked with the UK Zoos Expert Committee, an advisory body whose purpose is to provide independent, impartial and expert advice to Defra and UK zoo Ministers, on the new Standards. Following the consultation we have also undertaken extensive further stakeholder engagement to enable us to introduce clearer new” Source location Response from DEFRA (Update July 2025)
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 Publication of revised zoo standards cannot meet the spring 2020 timetable because wider expert engagement requires additional time.
Verbatim wording from the response “Defra is committed to addressing the issues raised in the Regulation 28 report by creating a robust set of standards which place clear, legally enforceable obligations on zoos, and which are reflected in the zoo inspection reporting process. As set out in our response, the SSSMZP are developed by working closely with the Zoos Expert Committee (ZEC), an advisory body whose purpose is to provide independent, impartial and expert advice to Defra. Defra is working at pace in order to have the new set of standards published by the timescale. However, Defra has been advised strongly by ZEC to allow more time to engage fully with a wider range of experts to ensure that the new SSSMZP meet the intended objectives of securing public safety and improving animal welfare.” Source location Response from DEFRA
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 Double-door systems, documented safe systems of work and lone-worker policies should sufficiently mitigate human-reliability and fatigue risks.
Verbatim wording from the response “We consider that the requirement for double-door systems for enclosures of Category 1A or Category 1 listed primates or terrestrial carnivores, along with a documented ‘Safe System of Work (SSOW) – as set out in 6.9 below - should mitigate the risks posed to public safety by human error due to worker fatigue.” Source location Response from DEFRA (Update July 2025)
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 Risks to zoo keepers from worker fatigue fall outside the remit of the new Standards and zoo inspection process.
Verbatim wording from the response “As explained in ████████’s letter of 4 September 2019, we believe that in relation to the risks posed to keepers as a result of worker fatigue, these fall outside the remit of the new Standards and the zoo inspection process. Licensing Authorities are prohibited by section 5(7) of the Zoo Licensing Act 1981 from attaching conditions to a licence that "...relate only or primarily to the health, safety or welfare of persons working in the zoo".” Source location Response from DEFRA (Update July 2025)
Open published response
8 Oct 2018 Natasha Charlotte Rose Ednan-Laperouse · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 4 Inadequate or unclear allergen labelling on packaging View source Failure to maintain a coherent and coordinated system for monitoring customer allergic reactions View source Inadequate adrenaline dose for anaphylaxis View source Use of adrenaline injector needles that fail to access muscle 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
Natasha Charlotte Rose Ednan-Laperouse · 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
Natasha Charlotte Rose Ednan-Laperouse, who was allergic to sesame, ate a baguette purchased from Pret-a-Manger that contained unlabelled sesame. She developed an anaphylactic reaction on a flight to Nice and died in hospital shortly after landing on 17 July 2016. The report raised concerns about inadequate allergen labelling, inadequate monitoring of customer allergic reactions, and the needle length and adrenaline dose of some autoinjectors used in emergency treatment.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unclear allergen labelling on packaging
Wider context from the report “(1) That allergens were not labelled adequately or clearly on Pret-a-Manger packaging when prepared in their kitchens “pre-packed for direct sale” utilising regulation 5 of the Food Information Regulations. Regulation 5 allows for food outlets to avoid full food labelling requirements whether they prepare a small number of items in local shops or in the case of Pret, over 200 million items for sale by preparing these items in “local kitchens”. These items prepared in “local kitchens” are in fact “assembled” in large parts from items made in factory style outlets to Pret specifications. I was left with the impression that the “local kitchens” were in fact a device to evade the spirit of the regulation.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a coherent and coordinated system for monitoring customer allergic reactions
Wider context from the report “(2) In the case of Pret-a-manger there was no coherent or co-ordinated system for monitoring customer allergic reactions despite sales of more than 200 million items. In some cases concerns were notified to Customer Services and in some they were noted to the safety department. The two did not know what the other was responding to. It was clear that there was no overarching monitoring system in place . In response to questioning on this I was told that the manager responsible for safety now received all notifications and would monitor them. In my view this remains highly inadequate. In my view sales of 200 million items some with expressly commissioned but hidden allergens require a robust safety auditing system. The previous system was unsafe and the system proposed equally so in my view .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Inadequate adrenaline dose for anaphylaxis
Wider context from the report “(4) The dose of adrenaline in Epipen is 300mcg . The UK Resuscitation Council recommends a standard emergency dose of 500mcg . Emerade contains a dose including 500mcg. The combination of what my expert told me was an inadequate dose of adrenaline for anaphylaxis and an inadequate length needle raises serious safety 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Use of adrenaline injector needles that fail to access muscle
Wider context from the report “(3) In the Emergency treatment of anaphylactic reactions Guidelines for healthcare providers the preferred needle length is 25 mm for adrenaline injectors to access muscle in most people. I heard during expert evidence that Epipen needle length was 16mm - suitable according to the UK Resuscitation Council for “pre-term or very small infants”. The use of needles which access only subcutaneous tissue and not muscle is in my view inherently unsafe . An alternative autoinjector, Emerade has a 24 mm needle.
” 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 Conduct an urgent review of allergen information requirements for food pre-packed for direct sale, including stakeholder engagement and development of policy options.
Verbatim wording from the response “Taking into account matter of concern (1) raised in your Regulation 28 report, an urgent review of allergen information provision for food which is pre-packed for direct sale is under way with a view to strengthening the framework.” Source location 2018-0279-Response-by-Department-for-Environment-Food-Rural-Affairs
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 Encourage businesses to implement best-practice approaches to allergen information provision.
Verbatim wording from the response “Our central concern is about improving consumer safety, and therefore, alongside the review, we are encouraging businesses to implement a best practice approach to allergen information provision. The FSA have also been working in collaboration with patient groups to run awareness campaigns such as #EasytoASK which works to promote best practice behaviour by consumers with allergies.” Source location 2018-0279-Response-by-Department-for-Environment-Food-Rural-Affairs
Open published response
5 Dec 2014 Jade Sarah Louise Lomas Anderson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Failure of current dog-control legislation to protect public safety and animal welfare View source Lack of educational awareness about staying safe around dogs View source Breed-specific dog-control legislation causing ineffective and inconsistent enforcement View source Failure to provide dogs with enrichment and regular exercise View source Fragmentation and lack of updating of dog-control legislation View source Dog trafficking from abroad increasing dog-control risks View source Failure of dog owners to ensure dogs are socialised and under control View source Reactive dog-control legislation delaying intervention before serious incidents View source Lack of coordinated and current dog-behaviour information for at-risk groups View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jade Sarah Louise Lomas Anderson · 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
Jade Sarah Louise Lomas Anderson died on 26 March 2013 after being attacked by more than one dog while alone in a house. The report raised concerns about inadequate control of dogs, limitations and fragmentation of dog-control legislation, insufficient owner responsibility and education, and the need for earlier intervention to prevent future incidents.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure of current dog-control legislation to protect public safety and animal welfare
Wider context from the report “iii. In the past four years the number of dog bite incidents that required hospital treatment has risen by 26% and the number of convictions for possessing prohibited dog types (three dog types) has risen by 146% whilst the number of convictions for not keeping dogs under control rose by 5%, which indicates that the approach set out in current Legislation is not working and continues to put public safety and animal welfare at risk .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of educational awareness about staying safe around dogs
Wider context from the report “vii. The key aspect that is missing from the current approach to tackling dog bites is educational awareness about staying safe around dogs .
The RSPCA is currently developing an education package for schools, families and others that provide simple and clear information about dog behaviour and in particular the signals dogs can give when they are stressed or uncomfortable in a situation. During the course of evidence I received a leaflet produced by the RSPCA and named ‘Dogs and Children, a Guide to staying safe’ with six golden rules for keeping a child safe and a dog happy.
The evidence indicated that a coordinated approach to ensure that all ‘at risk’ groups receive consistent and up to date information about dog behaviour is needed and other groups of people that may benefit from such an approach would be those who deliver to properties and services providers.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Breed-specific dog-control legislation causing ineffective and inconsistent enforcement
Wider context from the report “v. The current Legislation provides for controls over the possession of four types of dogs and the Legislation is word specific by reference to the type of dog rather than the behaviour of a dog . The evidence was that the behaviour of a dog is more important than the breed.
The Legislation is supported by a considerable amount of case law determining aspects of different pieces of Legislation, which often results in confusion amongst law enforcement practitioners (for example, dog wardens, police officers and other agencies) in selecting the best piece of Legislation to use leading to a lack of effective and consistent enforcement throughout England and Wales . This has often resulted in confusion amongst the public in terms of what is expected of them as responsible dog owners, as well as which agency should receive a complaint. An update and consolidation of dog control Legislation based upon up-to-date scientific understanding of dog behaviour and in particular aggression, which is not based upon a breed specific approach would assist front-line practitioners in relation to the control of dogs and the enforcement of Legislation so that the number of serious incidents could be reduced and prevented.
The evidence indicated that Legislation should not be based upon a breed specific approach and instead focus on the behaviour of the dog and the owner / person responsible for the dog. Furthermore it should allow for significantly earlier intervention so that serious incidents could be prevented.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure to provide dogs with enrichment and regular exercise
Wider context from the report “ii. An inspection of the premises at ████████ revealed a sign to the left of the front door ‘Beware of the Dog – Enter at your own Risk’. The premises were small and housed two adults, ████████, five dogs, a cat and a parrot. The dogs of the type and number described raised concerns with regard to potential problems in relation to interaction and dominance issues in a confined area. There was no evidence of dog toys or purpose made dogs to keep the dogs occupied and provide enrichment for them and there was no evidence of any dog collars or leads within the premises. There was no evidence that the dogs were given regular exercise or went out of the premises , other than to roam in the confined space of the rear garden.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Fragmentation and lack of updating of dog-control legislation
Wider context from the report “iv. The Legislation on dog control is scattered amongst many different pieces of Legislation and this does not include a range of secondary legislation. The main pieces of Legislation are within more than 10 statutes commencing with the Metropolitan Police Act 1839 and culminating in the Anti-Social Behaviour, Crime and Policing Act 2014, which comes into force in England and Wales in May 2014.
The provisions of the Anti-Social Behaviour, Crime and Policing Act 2014 were welcomed during the evidence but the evidence was that the recent Legislation did not go far enough to address the problem of the control of dogs, which had led to an increase in dog bite incidents.
The evidence indicated that only consolidated and updated Legislation would ensure that the public, owners of dogs and enforcers of the Legislation have a clear understanding of what is expected and what powers can be used .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Dog trafficking from abroad increasing dog-control risks
Wider context from the report “viii. Problems arising from the lack of control of dogs increases with an increase in the number of dogs in the country. The evidence was that there are nine and a half million dogs in the country and the practice of dog trafficking from abroad is prevalent, which increases the problem of dog control .
The evidence indicated that the Licencing of dogs with central records would assist front-line practitioners in the control of dogs and the enforcement of Legislation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Failure of dog owners to ensure dogs are socialised and under control
Wider context from the report “ix. The evidence indicated that a key issue in the control of dogs is to make owners responsible for their dogs and dog owners need to take sufficient steps to ensure that their pets are well socialised and under control so that they do not pose a risk to other people . The care of dogs, including proper exercise, and the provision of dog toys and purpose made dog beds, for example, would keep dogs occupied and provide enrichment for them, which would reduce the number of dog bite incidents. There is a need to educate dog owners in relation to such matters.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Reactive dog-control legislation delaying intervention before serious incidents
Wider context from the report “vi. The Legislation tends to be reactive rather than proactive so it is difficult to prevent serious incidents from occurring .
The evidence indicated that if the Legislation was proactive enforcement would be available at an early stage prior to incidents having occurred and would lead to the prevention of serious incidents.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated and current dog-behaviour information for at-risk groups
Wider context from the report “vii. The key aspect that is missing from the current approach to tackling dog bites is educational awareness about staying safe around dogs.
The RSPCA is currently developing an education package for schools, families and others that provide simple and clear information about dog behaviour and in particular the signals dogs can give when they are stressed or uncomfortable in a situation. During the course of evidence I received a leaflet produced by the RSPCA and named ‘Dogs and Children, a Guide to staying safe’ with six golden rules for keeping a child safe and a dog happy.
The evidence indicated that a coordinated approach to ensure that all ‘at risk’ groups receive consistent and up to date information about dog behaviour is needed and other groups of people that may benefit from such an approach would be those who deliver to properties and services providers.
” 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 Enable police and local authorities to intervene in low-level irresponsible dog ownership before conduct becomes dangerous.
Verbatim wording from the response “We have also responded to calls for the law to be more proactive. To this end, we made sure that the new measures to deal with anti-social behaviour, in the Anti-social Behaviour, Crime & Policing Act 2014, could be used to tackle such behaviour when it involves irresponsible ownership of a dog. These new laws mean that police and local authorities now have powers to intervene in cases of low level nuisance, before a serious incident occurs – for example, a dog running loose in a park or near a road, a dog that threatens visitors or creates a situation where there are too many dogs on a property and it is having a detrimental effect on the quality of life of those in the locality. This means that action can be” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
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 Produce and publish a Practitioner’s Manual to help enforcers apply irresponsible-dog-ownership measures appropriately.
Verbatim wording from the response “To help the police and local authorities use the new measures appropriately, Government produced a comprehensive Practitioner’s Manual. You can find the Manual on this link:
https://www.gov.uk/government/publications/dealing-with-irresponsible-dog-ownership-practitioners-manual
The Manual was drawn up with the co-operation of the practitioners themselves and animal welfare charities and has been widely welcomed. There are a number of scenarios envisaged in the document which help the practitioners deal with a range of specific incidents they might face, including complaints relating to dogs on a property.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
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 leading dog-advertising websites and charities to improve information for owners.
Verbatim wording from the response “I also note what you say about education and training of children around dogs. As you point out, there is already good work being carried out by the RSPCA in this area. Similarly, the Dogs Trust, Battersea Dogs & Cats Home and the Kennel Club all provide helpful advice about children and dogs, and we have been able to give them financial support to help them with this work. As the recognised experts in this area, I think the charities are better placed to give this advice to dog owners and keepers, and they are more likely to be needed than a Government leaflet. We and the charities are also working with the leading websites carrying advertisements for dogs to improve information for owners.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
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 Provide financial support to charities delivering education and training about children and dogs.
Verbatim wording from the response “I also note what you say about education and training of children around dogs. As you point out, there is already good work being carried out by the RSPCA in this area. Similarly, the Dogs Trust, Battersea Dogs & Cats Home and the Kennel Club all provide helpful advice about children and dogs, and we have been able to give them financial support to help them with this work. As the recognised experts in this area, I think the charities are better placed to give this advice to dog owners and keepers, and they are more likely to be needed than a Government leaflet. We and the charities are also working with the leading websites carrying advertisements for dogs to improve information for owners.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
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 Extend dangerous-dog offences and increase penalties for attacks causing death, injury, or harm to assistance dogs.
Verbatim wording from the response “The Government is serious about tackling irresponsible ownership of dogs which is why we have recently changed the existing law in two important respects.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training for police and local authority enforcers means consolidating dangerous-dog legislation is not considered a priority.
Verbatim wording from the response “In addition to the manual there is also a comprehensive training programme for police officers on the new laws on dogs. The police, in particular, are responsible for enforcing the law on dangerous dogs. Despite the law on dangerous dogs being in more than one statute, which is not unusual, the police have specifically trained officers to deal with such complaints – Dog Legislation Officers (DLOs). Nearly all forces have DLOs and where these are not available, they can be obtained from neighbouring forces. Local authorities also have access to dedicated Dog Wardens to deal with stray and displaced dogs. These too are specifically trained to handle dogs and are familiar with the law in this area. I therefore consider that training is already available to enforcers and that consolidation of the legislation on dangerous dogs is not a priority.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
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 Animal welfare charities are considered better placed than government to provide advice and education about children and dogs.
Verbatim wording from the response “I also note what you say about education and training of children around dogs. As you point out, there is already good work being carried out by the RSPCA in this area. Similarly, the Dogs Trust, Battersea Dogs & Cats Home and the Kennel Club all provide helpful advice about children and dogs, and we have been able to give them financial support to help them with this work. As the recognised experts in this area, I think the charities are better placed to give this advice to dog owners and keepers, and they are more likely to be needed than a Government leaflet. We and the charities are also working with the leading websites carrying advertisements for dogs to improve information for owners.” Source location 2014-0530 - Response from Department for Enviroment Food and Rural Affairs
Open published response
Concerns raised 4 Lack of standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing View source Lack of standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog View source Lack of independent verification of kennels’ dog re-homing policies and their implementation View source Lack of national or local standards for judging stray dog re-homing policies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lexi Branson · 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
Lexi Branson, aged 4¾ years, died after a dog attacked her in the living room of her home, causing extensive neck and facial injuries and preventing breathing. The report identified concerns about the absence of national or local standards for re-homing stray dogs, assessing dogs and applicants, and independently verifying kennel policies and their implementation.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments ;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog .
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of independent verification of kennels’ dog re-homing policies and their implementation
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local standards for judging stray dog re-homing policies
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged ;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” 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 Explore ways to disseminate best practice in dog rehoming checks to other organisations involved in rehoming.
Verbatim wording from the response “We will therefore write to the main dog rehoming centres (explaining the recommendations you have made) and explore ways in which best practice in dog rehoming checks can be disseminated to others involved in this activity.” Source location Response from Department for Enviroment Food and Rural Affairs
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 Most dog rehoming centres already identify behavioural concerns and unsuitable owner circumstances and take appropriate preventive steps.
Verbatim wording from the response “We realise that these new measures do not fall within the scope of your suggestions to which we have given serious consideration. We understand that re-homing centres need to be aware of any behaviour problems in their dogs. Thousands of dogs are rehomed every year and the vast majority cause no problems for their new owners. Most rehoming centres are responsible and will identify any dogs where the behaviour is a cause for concern or where the owner’s personal circumstances may not suit the dog in question. The problem with trying to apply standards in relation to testing a dog’s behaviour is that it is by no means an exact science. A dog might pass a behaviour test but it would not necessarily be a guarantee that the dog’s behaviour will not be a cause for concern once it is in new surroundings and with a new owner.” Source location Response from Department for Enviroment Food and Rural Affairs
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 Behaviour testing is not sufficiently exact or predictive to support mandatory standards guaranteeing that a dog's future behaviour will not cause concern.
Verbatim wording from the response “We realise that these new measures do not fall within the scope of your suggestions to which we have given serious consideration. We understand that re-homing centres need to be aware of any behaviour problems in their dogs. Thousands of dogs are rehomed every year and the vast majority cause no problems for their new owners. Most rehoming centres are responsible and will identify any dogs where the behaviour is a cause for concern or where the owner’s personal circumstances may not suit the dog in question. The problem with trying to apply standards in relation to testing a dog’s behaviour is that it is by no means an exact science. A dog might pass a behaviour test but it would not necessarily be a guarantee that the dog’s behaviour will not be a cause for concern once it is in new surroundings and with a new owner.” Source location Response from Department for Enviroment Food and Rural Affairs
Open published response
9 Jun 2014 Thomas Allen · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Police/local authority protocol not in force in Suffolk View source Lack of criminalisation of fly grazing in England 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
Thomas Allen · 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
Thomas Allen died from injuries sustained when five untethered horses entered the unlit A14 on Christmas Eve 2012, causing a series of collisions; he died the following day. The principal concerns were that fly grazing was a national problem, was not a criminal offence in England, and that a police/local authority protocol was not yet in force in Suffolk.
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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Police/local authority protocol not in force in Suffolk
Wider context from the report “Fly grazing is a national problem which is currently more difficult to curtail because
(1) It is not currently a criminal offence in England (although I understand that steps are being taken to remedy this in Wales)
(2) A police/local authority protocol is being worked on but not currently in force in Suffolk .
” 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 Environment, Food & Rural Affairs; that does not assign responsibility.
PFD Monitor interpretation Lack of criminalisation of fly grazing in England
Wider context from the report “Fly grazing is a national problem which is currently more difficult to curtail because
(1) It is not currently a criminal offence in England (although I understand that steps are being taken to remedy this in Wales)
(2) A police/local authority protocol is being worked on but not currently in force in Suffolk.
” 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 Existing laws and powers are considered sufficient to address horses straying onto highways and fly-grazing, so a specific offence is not proposed.
Verbatim wording from the response “I am grateful to you for drawing attention to this very sad case and I offer my condolences to Ms Chenery. You suggest that the provision of a specific offence of fly-grazing would help prevent such incidents in the future. However, we already have laws in place to tackle the straying of animals onto a highway. In particular, the Highways Act 1980; section 155 of which provides offences relating to straying livestock on a highway and which may be relevant in this case. Under the 1980 Act, the horses can be removed if they are straying onto, or are by the side of, the highway and the associated costs recovered from the owner of the horses.” Source location Response from DEFRA
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations