16 Apr 2025 Abdulrahman AlAjmi · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment View source Lack of a set procedure for UK hospital acceptance of patients from other countries View source Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer 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
Abdulrahman AlAjmi · 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
Abdulrahman AlAjmi died at the London Clinic on 7 August 2024 from multiorgan failure after arriving in the UK for medical treatment in a substantially poorer condition than had been reported. The report found that the flight probably contributed to his death by exacerbating serious pre-existing medical conditions. Concerns included the absence of uniform systems for accepting and transferring overseas patients, ensuring that receiving services have accurate and up-to-date medical information, and safely treating patients who arrive more unwell than anticipated.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment
Wider context from the report “5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated : with a full understanding of the accurate and up to date medical position.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a set procedure for UK hospital acceptance of patients from other countries
Wider context from the report “1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries .
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer
Wider context from the report “2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change .
” 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 Responding to the concern falls outside the respondent’s remit and is instead a matter for the Health Department.
Verbatim wording from the response “I don't believe a response sits within my remit and seems more for the Health Department [DHSC].” Source location Response from FCDO
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Health Department should liaise with the referring country’s health team to determine whether travellers are fit to travel.
Verbatim wording from the response “It’s about people travelling to the UK for medical procedures in a worse condition than anticipated. This would be for [DHSC] to liaise with the Health Team in the country who has sent the referral to determine if they are well enough to travel.” Source location Response from FCDO
Open published response
4 Jul 2024 Harry Peter DUNN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure of driving training to cover wrong-way driving risks View source Lack of UK driving familiarisation and training for diplomatic personnel 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
Harry Peter DUNN · 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
Harry Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The principal concern was that diplomatic personnel based at RAF Croughton were not provided with driver familiarisation or training, and that subsequent training may not have specifically covered the risks of wrong-way driving.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure of driving training to cover wrong-way driving risks
Wider context from the report “(5) Written evidence submitted by the US Embassy and read out at the inquest advised that since Mr Dunn’s death driver training was now provided to all personnel, including family members, assigned to the US Mission wherever they are based in the UK. In addition at RAF Croughton further training was provided for newly arrived US Personnel which included a mandatory local conditions driver safety briefing focussed on the dangers of wrong – way driving.
(6) However the evidence heard at the inquest as to the content of that briefing / training was at odds with what had been described by the US Embassy. Specifically I was told that the driving training being provided did not specifically cover the risks of wrong way driving .
(7) That creates a concern for me as to a risk of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of UK driving familiarisation and training for diplomatic personnel
Wider context from the report “(2) In terms of driver training provision there was a distinction between what was provided to the US Military and what was provided, or rather not provided, to Diplomatic personnel . The input provided to the US military personnel amounted to a driver briefing and the completion of a UK theory driving test. Nothing was provided to the diplomatic personnel .
(3) ████████ had received no familiarisation or any other form of training between her arrival in the UK on 24 July 2019 and the accident on 27 August 2019. Prior to the accident she had passed a thorough arrow signalling to a driver if they happened to be overtaking to get back to the left hand side. However, ████████ had not yet familiarised herself with the UK Highway Code and neither had she been trained in the differences in and significance of road signs in the UK .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with US Visiting Forces and the US Embassy to maintain focus on driver training and road safety awareness.
Verbatim wording from the response “There is a continual need to focus on the issue of driver training and road safety awareness, especially as military forces and diplomats rotate through the UK. We are committed to continue work with the US to maintain our focus on this. We will be meeting the representatives of US Visiting Forces and the US Embassy in London again next month to do so.” Source location Response from MOD & FCDO
Open published response
3 Jul 2024 Andrew James STORY · Prevention of Future Deaths report Cheshire
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Concerns raised 3 Particularly rough sea conditions making swimming unsafe View source Absence of red warning markers, signs or flags at the beach and sea View source Lack of lifeguards on duty during the summer season View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew James STORY · 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
Andrew Story died after drowning while swimming in the sea in Rethymno, Crete, on holiday; a UK post-mortem also identified left ventricular hypertrophy. The report raised concerns that the sea was particularly rough, there were no lifeguards on duty, and there were no red warning markers, signs or flags to indicate the danger.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Particularly rough sea conditions making swimming unsafe
Wider context from the report “It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season. This coincided with tourist season making the use of that beach and sea for swimming generally, and particularly unsafe in the absence of red warning markers, signs or flags
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Absence of red warning markers, signs or flags at the beach and sea
Wider context from the report “It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season. This coincided with tourist season making the use of that beach and sea for swimming generally, and particularly unsafe in the absence of red warning markers, signs or flags
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of lifeguards on duty during the summer season
Wider context from the report “It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season . This coincided with tourist season making the use of that beach and sea for swimming generally, and particularly unsafe in the absence of red warning markers, signs or flags
” Open source report
1 Nov 2023 Musa Sidique Konteh · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to supply lifejackets to people hiring jet skis View source Failure to provide jet ski hirers with emergency engine cut-off instructions View source Failure of travel advice to warn travellers that local health and safety standards may be lower than in the UK View source Failure to provide jet ski hirers with instructions on areas to avoid View source See 1 more concern
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
Musa Sidique Konteh · 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
Musa Sidique Konteh went missing after hiring a jet ski alone at a beach resort in Sierra Leone on 19 March 2023; his body was found in the water on 22 March 2023. Concerns included the reported lack of health and safety procedures for jet-ski users, including no emergency engine cut-off instructions, no guidance about submerged rocks, and no supplied lifejackets, as well as travel advice that did not warn that local health and safety standards might be lower than those experienced in the UK.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to supply lifejackets to people hiring jet skis
Wider context from the report “(1) Little, if any, health and safety procedures were in place for those hiring jet skis. For example: no instructions on the use of the emergency engine cut-off were given; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks; and no lifejackets were supplied to people hiring jet skis .
(2) The relevant Foreign, Commonwealth and Development Office travel advice, warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide jet ski hirers with emergency engine cut-off instructions
Wider context from the report “(1) Little, if any, health and safety procedures were in place for those hiring jet skis. For example: no instructions on the use of the emergency engine cut-off were given ; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks; and no lifejackets were supplied to people hiring jet skis.
(2) The relevant Foreign, Commonwealth and Development Office travel advice, warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure of travel advice to warn travellers that local health and safety standards may be lower than in the UK
Wider context from the report “(1) Little, if any, health and safety procedures were in place for those hiring jet skis. For example: no instructions on the use of the emergency engine cut-off were given; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks; and no lifejackets were supplied to people hiring jet skis.
(2) The relevant Foreign, Commonwealth and Development Office travel advice, warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK .
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide jet ski hirers with instructions on areas to avoid
Wider context from the report “(1) Little, if any, health and safety procedures were in place for those hiring jet skis. For example: no instructions on the use of the emergency engine cut-off were given; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks ; and no lifejackets were supplied to people hiring jet skis.
(2) The relevant Foreign, Commonwealth and Development Office travel advice, warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK.
” Open source report
9 Oct 2023 Sandra Curran · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of warnings about local sea conditions, swimming risks and risk mitigation for weak swimmers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Curran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sandra Curran died after becoming unresponsive while snorkelling in the sea off Bugibba Saint Paul's, Malta, on 4 July 2022; an investigation found that she died from asphyxia as a consequence of drowning. The principal concern was that UK tour operator welcome information did not warn about the risks and challenges of sea swimming or snorkelling in Malta, particularly for weak swimmers.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about local sea conditions, swimming risks and risk mitigation for weak swimmers
Wider context from the report “The inquest heard the Mrs Curran had booked her holiday through a UK Tour operator. Mrs Curran was not a strong swimmer and that she was unaware of the risks that swimming/snorkelling in the sea off the coast of Malta could present. No warnings were given in the welcome information/briefing about the challenge the sea around the coast in Malta could present to a weak swimmer. Previously when she had snorkelled it had been in far easier conditions where the risks of strong currents had not been present. The evidence given by her family at the inquest was that had her tour operator highlighted the need for caution Mrs Curran would not have snorkelled alone in the area where she drowned. A more proactive approach by UK tour operators highlighting the risk of getting into difficulties and how to mitigate them would reduce the risk of further deaths in circumstances such as Mrs Curran’s.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the Travel Aware campaign prompting British nationals to read destination advice and subscribe to travel alerts.
Verbatim wording from the response “The FCDO’s established public-facing Travel Aware communications campaign will continue to prompt British nationals who are planning to travel abroad to read the latest FCDO travel advice for their destination and to sign up for e-mail alerts.” Source location Response from Foreign, Commonwealth and Development Office
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 Enhance cooperation with the Royal Life Saving Society and support water-safety information on its website during the summer holiday season.
Verbatim wording from the response “We work closely with foreign governments, partners in the travel industry and others to reduce the risks to British people when they travel abroad. This year we enhanced our cooperation with the Royal Life Saving Society and worked with them on the water safety information appearing on their website during the summer holiday season. We will continue to work with ABTA and the travel industry and fully endorse efforts to make their customers aware of the risks they may face during travel.” Source location Response from Foreign, Commonwealth and Development Office
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 Enhance Travel Advice on swimming safety by linking to the Royal Life Saving Society’s Water Safety on Holiday guidance.
Verbatim wording from the response “In light of your report, we have considered further our advice on water risks in Malta:” Source location Response from Foreign, Commonwealth and Development Office
Open published response
4 Feb 2023 Kirsty Margaret McKie · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of awareness of methanol consumption risks among expatriate and tourist communities View source Methanol being passed off as alcohol for human consumption View source Lack of UK Government publicity about methanol risks to UK nationals travelling abroad View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Margaret McKie · 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
Kirsty Margaret McKie lived and worked in Bali and died in hospital on 24 July 2022 after unknowingly consuming methanol that had been sold as alcohol fit for human consumption. The report identifies concerns about low awareness of methanol poisoning risks among expatriates and tourists and limited UK Government publicity about those 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of methanol consumption risks among expatriate and tourist communities
Wider context from the report “The Inquest heard evidence that there is a growing problem of methanol being passed off as alcohol for human consumption particularly in places such as Bali. Methanol is used rather than ethanol in spirits aimed at the Western market and sold even through apparently reputable suppliers.
The evidence before the Inquest was that :
1. Knowledge of the problem amongst the expatriate/tourist community was very low despite the increase in the problem and the catastrophic consequences of methanol consumption;
2. There was little publicity by the UK Government of the risk in contrast to the approach taken by the Australian Government who had undertaken a campaign to increase awareness to protect their citizens travelling in areas of Asia such as Bali;
3. The UK Government publicising information about the risk of methanol being used in local spirits, steps that could be taken by UK nationals travelling to reduce the risk and warning signs of methanol toxicity would help to reduce the chance of others dying in the way in which Kirsty McKie died.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Methanol being passed off as alcohol for human consumption
Wider context from the report “The Inquest heard evidence that there is a growing problem of methanol being passed off as alcohol for human consumption particularly in places such as Bali . Methanol is used rather than ethanol in spirits aimed at the Western market and sold even through apparently reputable suppliers .
The evidence before the Inquest was that :
1. Knowledge of the problem amongst the expatriate/tourist community was very low despite the increase in the problem and the catastrophic consequences of methanol consumption;
2. There was little publicity by the UK Government of the risk in contrast to the approach taken by the Australian Government who had undertaken a campaign to increase awareness to protect their citizens travelling in areas of Asia such as Bali;
3. The UK Government publicising information about the risk of methanol being used in local spirits, steps that could be taken by UK nationals travelling to reduce the risk and warning signs of methanol toxicity would help to reduce the chance of others dying in the way in which Kirsty McKie died.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of UK Government publicity about methanol risks to UK nationals travelling abroad
Wider context from the report “The Inquest heard evidence that there is a growing problem of methanol being passed off as alcohol for human consumption particularly in places such as Bali. Methanol is used rather than ethanol in spirits aimed at the Western market and sold even through apparently reputable suppliers.
The evidence before the Inquest was that :
1. Knowledge of the problem amongst the expatriate/tourist community was very low despite the increase in the problem and the catastrophic consequences of methanol consumption;
2. There was little publicity by the UK Government of the risk in contrast to the approach taken by the Australian Government who had undertaken a campaign to increase awareness to protect their citizens travelling in areas of Asia such as Bali;
3. The UK Government publicising information about the risk of methanol being used in local spirits, steps that could be taken by UK nationals travelling to reduce the risk and warning signs of methanol toxicity would help to reduce the chance of others dying in the way in which Kirsty McKie died.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Place methanol-poisoning information banners at Bali international airport and disseminate them through social media channels.
Verbatim wording from the response “In response to the report, the British Consulate in Bali has reached agreement with the local airport authorities to place an information banner (hardcopy and digital on all airport TVs) about the risks of methanol poisoning in the international arrival area live from June to December this year. Permission to display the banner will be reviewed annually. The Consulate will also post the digital banner on their Facebook and Twitter pages, and will encourage people to re-post it to reach a wider audience. Once the banner design is ready, they will also share it with local social media groups.” Source location Response from Foreign, Commonwealth and Development Office
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 Ask Student Brand Ambassadors to promote methanol-poisoning warnings through social media and blogs.
Verbatim wording from the response “We will also ask our Student Brand Ambassadors, a network of young people made up from UK universities and Further Education colleges to warn people of the dangers of methanol poisoning, not limited to travel to Bali, and ask them to amplify our key messaging, via social media and blogs.” Source location Response from Foreign, Commonwealth and Development Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider reflecting methanol-poisoning risks in travel advice for other countries.
Verbatim wording from the response “We are also considering if there is a need to reflect the risks associated with methanol poisoning in any other country travel advice to help British nationals to make better-informed decisions when they travel. We will consider how to represent this alongside other risks to British nationals so that we set out all relevant risks proportionally.” Source location Response from Foreign, Commonwealth and Development Office
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 Update Indonesia travel advice to explain methanol risks, symptoms and steps to reduce exposure.
Verbatim wording from the response “We have considered how we might further strengthen this language and, in consultation with relevant UK health agencies, have updated travel advice to better illustrate the risk of methanol poisoning in Indonesia, the likely symptoms, and actions British nationals might take to try to avoid this happening.” Source location Response from Foreign, Commonwealth and Development Office
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 Continue the established Travel Aware campaign directing travellers to current travel advice and email alerts.
Verbatim wording from the response “More broadly, the FCDO’s established Travel Aware campaign will continue to prompt British nationals who are planning to travel abroad to read the latest FCDO travel advice for their destination and to sign up for e-mail alerts.” Source location Response from Foreign, Commonwealth and Development Office
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 Engage UK travel-industry contacts to highlight methanol-poisoning messaging to customers.
Verbatim wording from the response “We will engage our contacts in the UK Travel Industry to make them aware of the risks of methanol poisoning and highlight our messaging in Travel Advice allowing travel firms to bring the issue to the attention of their customers.” Source location Response from Foreign, Commonwealth and Development Office
Open published response
13 Nov 2022 Lee Bradley Brown · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of an emergency access protocol for consular officers to reach detained British nationals View source Insufficient FCDO travel advice on the possible circumstances and consequences of detention in Dubai View source Procedures failing to secure consular access for detained British nationals experiencing a mental health crisis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Bradley Brown · 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
Lee Bradley Brown was detained at Bur Dubai Police Station in Dubai after his arrest on 7 April 2011 and was found unresponsive in his solitary cell on 12 April 2011. The inquest identified concerns including beatings, inadequate food and water, unh abitable living conditions, lack of necessary medical care, and lack of access to consular services. It also heard concerns about emergency access protocols, travel advice about detention in Dubai, and procedures for providing consular access to detained British nationals experiencing a mental health crisis.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of an emergency access protocol for consular officers to reach detained British nationals
Wider context from the report “1. The inquest heard evidence that there is no emergency access protocol to ensure that consular officers can reach detained British nationals in the event of a reported emergency .
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient FCDO travel advice on the possible circumstances and consequences of detention in Dubai
Wider context from the report “2. The inquest heard concerns in relation to the current FCDO travel advice. There was considered to be insufficient information relating to the possible consequences of detention in Dubai (and the possible circumstances of such detention) . The inquest heard that the number of new cases of British Nationals reporting allegations of torture or mistreatment in Dubai to the FCDO has risen from 3% of the global total in 2016 to 13% of the global total in 2020.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Procedures failing to secure consular access for detained British nationals experiencing a mental health crisis
Wider context from the report “3. A concern was raised at the inquest in relation to the procedures in place to gain consular access to detained British nationals who may be suffering from a mental health crisis . Such British nationals may not be able to provide the necessary consent for consular services .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider how to reflect detention-related risks, including torture or mistreatment, in travel advice covering the UAE and other countries.
Verbatim wording from the response “Our consular team responsible for foreign travel advice is considering how we could reflect the risks associated with detention across the globe – including the UAE – in a way that enables British nationals to make better-informed decisions when they travel. We will consider how to represent this alongside other risks to British nationals so that we set out all the relevant risks, including those of torture or mistreatment, proportionately. A broader internal review of FCDO Travel Advice is underway. We will ensure the findings of the report are included in that work. The review is expected to be completed in mid-2023.” Source location Response from Foreign, Commonwealth & Development Office
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 Develop and implement improved mental-health training packages and enhanced specialist support for consular staff.
Verbatim wording from the response “whether the local treatment is appropriate. Where more specialist expertise and advice is required, consular staff have access to mental health experts in the FCDO who are able to guide and, where necessary, provide contact and liaison assistance with social services and other relevant providers.” Source location Response from Foreign, Commonwealth & Development Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the broader internal review of FCDO travel advice and include its findings in that work.
Verbatim wording from the response “Our consular team responsible for foreign travel advice is considering how we could reflect the risks associated with detention across the globe – including the UAE – in a way that enables British nationals to make better-informed decisions when they travel. We will consider how to represent this alongside other risks to British nationals so that we set out all the relevant risks, including those of torture or mistreatment, proportionately. A broader internal review of FCDO Travel Advice is underway. We will ensure the findings of the report are included in that work. The review is expected to be completed in mid-2023.” Source location Response from Foreign, Commonwealth & Development Office
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 Codify a Global Response Centre protocol for emergency calls involving risk to life.
Verbatim wording from the response “GRC colleagues are specifically trained and use their professional judgement to decide when to escalate a call out of hours or contact a colleague for assistance in country. Nevertheless, as a result of the inquest, we have codified a protocol for the GRC to follow in the event of an emergency call where there is a risk to life. We have also reminded GRC staff of our guidance on cases of torture and mistreatment (T&M). By 31 January 2023 all those working GRC shifts will have attended refresher training by FCDO’s Human Rights Advisers on our consular guidance on T&M cases. Training on best practice in T&M cases has also been delivered to consular officers across the consular network over recent years.” Source location Response from Foreign, Commonwealth & Development Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider how detention-related risks should be represented proportionately alongside other travel risks.
Verbatim wording from the response “Our consular team responsible for foreign travel advice is considering how we could reflect the risks associated with detention across the globe – including the UAE – in a way that enables British nationals to make better-informed decisions when they travel. We will consider how to represent this alongside other risks to British nationals so that we set out all the relevant risks, including those of torture or mistreatment, proportionately. A broader internal review of FCDO Travel Advice is underway. We will ensure the findings of the report are included in that work. The review is expected to be completed in mid-2023.” Source location Response from Foreign, Commonwealth & Development Office
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 Operate a Consular Contact Centre that triages consular calls and directs cases requiring assistance to relevant teams.
Verbatim wording from the response “Since 2011, post Mr Brown’s death, we have developed further our overall consular services and our operating methods so that our 24/7 response is as effective as possible. We continue to refine and improve our services for the benefit of British nationals abroad who seek our support and help. Since 2017, a Consular Contact Centre (CCC) has triaged all consular calls no matter which country in the world they relate to or originate from every day of the year. They respond to the majority of queries” Source location Response from Foreign, Commonwealth & Development Office
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 Host states and local authorities are responsible for the safety, security and welfare of detained British nationals.
Verbatim wording from the response “It is important to begin by noting that the safety and security of individuals in a foreign jurisdiction is the responsibility of the host state and the relevant local authorities.” Source location Response from Foreign, Commonwealth & Development Office
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 Access to specific prisons or detainees cannot be guaranteed urgently because it depends on local authorities facilitating visits.
Verbatim wording from the response “The local police or prison authorities have the responsibility for the welfare of all detainees and usually deal with arrangements for visiting or speaking to a detainee. We are reliant on the local authorities for the facilitation of visits and we cannot guarantee access will be given to any specific prison or detainee on an urgent basis or on a specific date.” Source location Response from Foreign, Commonwealth & Development Office
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 Consular officers are not trained or expected to determine mental capacity or assess whether local treatment is appropriate.
Verbatim wording from the response “FCDO staff are trained to help identify cases where an individual may have poor mental health and where they may require further assistance or may need their case to be prioritised. However, consular officers are not trained or expected to take a view on whether someone has capacity to make decisions on their own behalf or to comment on” Source location Response from Foreign, Commonwealth & Development Office
Open published response
Concerns raised 1 Lack of well-informed travel guidance about participation in Yage-consuming tribal ceremonies 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
Henry Jack MILLER · 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
Henry Miller died on 23 April 2014 in Colombia after consuming a psychoactive substance during a tribal ceremony and becoming intoxicated. The concern was whether travellers planning to participate in such ceremonies should receive warnings or advice before travelling and deciding whether participation was safe.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of well-informed travel guidance about participation in Yage-consuming tribal ceremonies
Wider context from the report “Many travellers go to this area of Columbia and some will consider participating in a tribal ceremony when Yage will be consumed. Many will check with the FCO about any issues or warnings about their travel plans. I would therefore ask you to consider whether a warning or advice should be issued to such travellers exploring this area of Columbia so that they can receive well informed guidance before travelling and deciding whether it is safe to participate in such a ceremony.
” 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 and update travel advice for Colombia and Bolivia to warn about risks associated with spiritual cleansing ceremonies.
Verbatim wording from the response “Colleagues at the British Embassy in Bogota have been following local developments in this case closely and we have been in contact with Mr Miller’s family. Following receipt of your report, our South America team finalised a review of our travel advice for Colombia and the wider region. We concluded that it was appropriate to include information on the risks of participating in spiritual cleansing ceremonies in our travel advice for Colombia and Bolivia. These updates were made on 31 August 2018. The extract from our travel advice for Colombia, found in the ‘Local laws and customs’ section, is as follows:” Source location 2018-0260-Response-by-FCO
Open published response
Concerns raised 1 Failure to maintain open communication channels for people in Britain seeking consular assistance with medical treatment abroad 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
Adrian Nicholas 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
Adrian Nicholas King became unwell and collapsed after riding a quad bike into the desert during an excursion in Egypt, and died in hospital from kidney failure on 29 May 2017. The principal concerns were that problems with his insurance affected the extent of his medical treatment and that attempts by his family to contact the British consulate for assistance were unsuccessful; it remained unanswered whether he could have been saved.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain open communication channels for people in Britain seeking consular assistance with medical treatment abroad
Wider context from the report “The indication given to me in evidence at the inquest was that the extent of Mr King’s medical treatment had been affected by problems with his insurance cover. Family members told me that when they became aware of his illness and hospitalization in Egypt they made numerous telephone calls attempting to speak to the consulate in Egypt in an effort to assist with what was going on. These calls were either not answered or curtailed very quickly without progress being made. It is not possible to say if it is likely that Mr King could have been saved but this remains an unanswered possibility. However it strikes me as important that if people in Britain are seeking to contact a British embassy or consulate abroad in order to assist with medical treatment for someone who is ill in that foreign country then the channel of communication should be open .
For the avoidance of doubt this concern relates to events prior to death. It has nothing to do with Coroners seeking to obtain information from abroad after a body from abroad comes back to England and Wales. That system is presently managed by ████████ and I am grateful for the assistance it provides on a regular basis.
” 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 Remind consular managers and staff of policy guidance and best practice for timely case action.
Verbatim wording from the response “Consular staff were in daily contact with Mr King’s family from 25 May 2017. But I accept that more effort should have been made to reach out to the family more quickly once they were notified of Mr King’s admittance to Al Kauther hospital in Hurghada on 22 May 2017. The Consular Regional Operations Manager and consular staff have since been reminded of the policy guidance and best practice and to ensure appropriate action is taken in a timely manner for all cases. If the family wish to provide more detail of the dates and times where they were not able to get hold of a member of the Consular team we will of course investigate further.” Source location 2018-0061-Response-by-Foreign-Commonwealth-Office
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 Operate in-house Consular Contact Centres providing continuous access to consular assistance by telephone worldwide.
Verbatim wording from the response “Whether or not consular officers can influence treatment decisions in foreign hospitals, it is very important to me that British people are able to make contact with our consular staff when they need our support. Since July 2017 all consular calls to” Source location 2018-0061-Response-by-Foreign-Commonwealth-Office
Open published response
Concerns raised 2 Lack of board-level security advisors in travel companies View source Failure by holiday and travel sellers to prominently display Travel Aware information and links View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher Bell and 29 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thirty British nationals were killed in a terrorist attack at the Imperial Mahaba Hotel in Sousse, Tunisia, on the morning of 26 June 2015. The concerns identified were whether travel companies had board-level security expertise and whether holiday and travel websites provided sufficiently prominent information about terrorist risks through the Government’s Travel Aware programme.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of board-level security advisors in travel companies
Wider context from the report “(1) I heard evidence that prior to the attack neither TUI nor other travel companies had security advisors on their boards . The evidence of a TUI witness was that “security was a matter for the accommodation hoteliers and providers”. I am informed that TUI now have such an advisor. However I remain concerned that if other companies do not have similar security advisors at board level then hotels which they use will not be adequately protected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure by holiday and travel sellers to prominently display Travel Aware information and links
Wider context from the report “(2) I heard evidence that prior to the attack, TUI's websites for Thomson and First Choice did not prominently display logos and links to the Government’s Travel Aware programme , which provides detailed travel advice for every country on the Foreign and Commonwealth Office website. I heard evidence that TUI have taken steps to change their website and promote literature to make these logos and links more prominent. I remain concerned that other companies which sell holidays, or sell flights and hotel accommodation separately, may not have taken such steps , as a result of which members of the public receive insufficient information about the risks of terrorist attacks in destination countries .
” Open source report
Concerns raised 1 Lack of cardiopulmonary resuscitation training for custody officers in Spain 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
Antony Miles Abbott · 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
Antony Miles Abbott was arrested on 23 October 2015 and held in a cell at Benidorm Police Station, Spain, where he was found with a soft loose ligature around his neck after no officer presence was observed for 18 minutes. The jury concluded that he died by hanging and recorded misadventure, with his death contributed to by neglect. Concerns included the lack of CCTV and an audible means of attracting attention in the cell, the failure to implement prior recommendations for custody surveillance and cell safety, and the absence of CPR training for custody officers.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of cardiopulmonary resuscitation training for custody officers in Spain
Wider context from the report “In addition evidence was given at the Inquest that whilst Custody Officers in Spain must be trained to administer first aid to detained persons, that training does not include training in the administration of Cardio Pulmonary Resuscitation (CPR) . These matters are reported in order that they can be brought to the attention of the relevant Authorities in Spain through the appropriate channels.
” Open source report
Concerns raised 3 Failure of holidaymaker safety advice to identify dangers at particular beaches View source Particularly high risk of death on the beach View source Ongoing dangerous currents at the beach 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
Mr Edwin Richard Flett · 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
Mr Edwin Richard Flett drowned after entering the sea at Accra (Rockley) Beach, Barbados, on 21 March 2015; prompt CPR could not save him, and the autopsy found no medical reason for the drowning. The report raised concerns about the beach's history of drownings, currents and riptides, the absence of warning flags or signs, and general rather than beach-specific safety information for tourists.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure of holidaymaker safety advice to identify dangers at particular beaches
Wider context from the report “3. The steps that the FCO has taken since this death is to produce general advice noting that warning flags and lifeguards may not be present on all beaches and that there may be unexpected currents. The advice about risks of swimming in general do not appear to draw the attention of holiday makers the risks acknowledged by the Barbados National Conservation Commission and evidenced by the family on this beach in particular.
4. The British tour operator now draws the attention of holiday makers to FCO advice and there is a general leaflet warning swimmers of dangers of swimming, precautions and of rip tides and listed lifeguard supervised beaches. But this advice remains general and does not inform holiday makers of dangers at particular beaches.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Particularly high risk of death on the beach
Wider context from the report “1. There is evidence of a particularly high risk of death on this beach. There were seven deaths acknowledged by the Minister of Tourism between 2000 and 2015. Mr David Flett, son, has researched the deaths using the internet and press reports. His evidence was of finding 3 in 2009, 2 in 2014 (one may be at another beach) and 3 in 2015. In this period from 2009 there were reported to be 23 drownings over the whole island. If this data is correct it would appear that 30% of the nation’s drownings occur on this beach ████████ reports that her taxi driver told her that locals called the beach as “The Graveyard”. No data before 2009 was available. If there were no deaths prior to 2009 on this beach in the previous 9 years an explanation would seem to be needed to explain the sudden increase. Alternatively there may have been other unreported deaths prior to 2009, and thus the annual mortality rate may be very much higher than the Ministry suggested.
” 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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Ongoing dangerous currents at the beach
Wider context from the report “2. The Barbados National Conservation Commission documentary evidence was that this beach had three currents: undertows, lateral/littoral currents/long shore drift and rip including flesh rips . The risks of these to swimmers were acknowledged and would seem to be on going and thus pertain both before 2009 and after 2015. Nevertheless, the report found no evidence that Mr Flett was in difficulty as a result of abnormal sea conditions, riptides or undercurrents, but the family see no other explanation of the sudden and unexpected drowning.
” Open source report
Concerns raised 10 Failure of Tour Operators to collaborate and share health and safety information View source Failure to provide carbon monoxide detectors in accommodation with individual gas appliances View source Lack of a central register and up-to-date energy-source and service-history information for holiday premises View source Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises View source Delegation of health and safety checks to inexperienced and overworked Tour Representatives View source Failure to provide clear traveller information about carbon monoxide dangers and safeguards View source Lack of robust internal health and safety management, supervision, support and training View source Lack of publicly accessible accommodation health and safety inspection reports View source Lack of suitably qualified specialist health and safety inspections at holiday accommodation View source Failure to carry out annual accommodation safety audits View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.
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 Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Tour Operators to collaborate and share health and safety information
Wider context from the report “2. In most situations a hotel, apartment or other holiday premises will be used by more than one Tour Operator. In this event a system should be devised for Tour Operators to work in collaboration with communicate and actively share information pertaining to Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carbon monoxide detectors in accommodation with individual gas appliances
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises.
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation , which has individual gas appliances , whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a central register and up-to-date energy-source and service-history information for holiday premises
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises .
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Delegation of health and safety checks to inexperienced and overworked Tour Representatives
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task . The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear traveller information about carbon monoxide dangers and safeguards
Wider context from the report “7. All holiday brochures and travel promotional literate and Health and Safety information should be written in clear, easy to understand language and should make specific reference to the dangers of carbon monoxide poisoning , and make reference to safeguards that travellers should adopt .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of robust internal health and safety management, supervision, support and training
Wider context from the report “6. Within the structure and hierarchy of every provider of hotels, apartments and holiday premises there should be a robust internal structure for a system of management, supervision support and training in respect of Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly accessible accommodation health and safety inspection reports
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible . In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Lack of suitably qualified specialist health and safety inspections at holiday accommodation
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety . Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks , the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Foreign, Commonwealth & Development Office; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out annual accommodation safety audits
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period .
” Open source report
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Addressed to Foreign & Commonwealth Office, now represented here by Foreign, Commonwealth & Development Office.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations