Recipient

Institution of Occupational Safety and Health

First report 23 May 2014•Latest report 23 May 2014

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Professional membership body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 8
Stated actions: 2

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Institution of Occupational Safety and Health linked to the concerns in each report. Select any concern, action or position to view the source wording.

23 May2014
Essex
Concerns raised8
1. Failure to ensure trained aquatic rescue staff are present when the pool is open
2. Inherently dangerous pool profile
3. Unclear, inaccurate and ambiguous pool signage
1. Failure to obtain swimming pool expert advice on controls for unsupervised pool use
2. Failure to provide lifeguards or effective drowning-risk controls
3. Failure to consider non-swimmers and poor swimmers in risk assessments
4. Failure to assess the pool profile and specific risk factors
5. Failure to monitor CCTV supervision and provide a contingency when unavailable
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

Josephine Foday and Komba Kpakiwa · 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

Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure trained aquatic rescue staff are present when the pool is open
Wider context from the report
“8) The pool operators did not ensure that in a pool of over 1.5m depth there were always on the premises, when the pool was open, staff trained in aquatic rescue techniques. ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Inherently dangerous pool profile
Wider context from the report
“1) The pool profile was inherently dangerous ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Unclear, inaccurate and ambiguous pool signage
Wider context from the report
“7) Some of the signage provided was not clear, accurate and unambiguous. ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain swimming pool expert advice on controls for unsupervised pool use
Wider context from the report
“6) The pool operators had not sought the advice of a swimming pool expert in order to decide what would constitute adequate controls where constant pool supervision was not provided in this unusual hopper type pool. The operators were relying on CCTV as a method of supervision but this was not monitored and no system was put in its place when it became unavailable. ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide lifeguards or effective drowning-risk controls
Wider context from the report
“4) There were no lifeguards provided and the duty holders of the pool did not ensure that there were in place effective controls in place to reduce the risk of drowning ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider non-swimmers and poor swimmers in risk assessments
Wider context from the report
“5) It did not appear that non swimmers or poor swimmers had been considered in the risk assessment process. ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess the pool profile and specific risk factors
Wider context from the report
“2) The pool profile, including depths and gradients were not considered when carrying out the hazard identification that is required in the swimming pool guidance document HSG 179 3) The risk assessments did not cover the accurate profile information and any other specific risk factors ”
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 Institution of Occupational Safety and Health; that does not assign responsibility.
PFD Monitor interpretation
Failure to monitor CCTV supervision and provide a contingency when unavailable
Wider context from the report
“6) The pool operators had not sought the advice of a swimming pool expert in order to decide what would constitute adequate controls where constant pool supervision was not provided in this unusual hopper type pool. The operators were relying on CCTV as a method of supervision but this was not monitored and no system was put in its place when it became unavailable. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure to ensure trained aquatic rescue staff are present when the pool is open

Inherently dangerous pool profile

Unclear, inaccurate and ambiguous pool signage

Failure to obtain swimming pool expert advice on controls for unsupervised pool use

Failure to provide lifeguards or effective drowning-risk controls

Failure to consider non-swimmers and poor swimmers in risk assessments

Failure to assess the pool profile and specific risk factors

Failure to monitor CCTV supervision and provide a contingency when unavailable