19 Apr 2026 Paul HUTCHINSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures View source Failure of Fire Risk Assessments to account for vulnerable residents at special risk View source Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements View source Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors View source Lack of specific requirements for emergency equipment and staff training View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul HUTCHINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise staff training on evacuation, alarm, telecare and fire suppression procedures
Wider context from the report “2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems .
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure of Fire Risk Assessments to account for vulnerable residents at special risk
Wider context from the report “3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming 'any group of persons identified...as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not take this into account .
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of timescales for regular reviews of PCFRAs and personal emergency evacuation arrangements
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change) . This concern may apply to others in formal residential care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for PCFRAs and personal emergency evacuation plans with agreed formats and risk factors
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors , a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for emergency equipment and staff training
Wider context from the report “1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings. The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.
” Open source report
29 Jul 2024 Lamarah Grace Scarlett · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 9 Lack of a requirement for transport crew to be qualified first aiders View source Lack of a comprehensive schedule for inspection of transport operators View source Lack of mandatory training or forums for transport operators to receive cascaded information View source Inadequacy of the passenger assessment test View source Fragmented access to organisations causing confusion and inconsistency for transport operators View source Failure of transport crew to read and understand patient safety plans View source Failure to conduct contractually required home visits between passengers and transport crew View source Failure to notify the local authority of transport crew personnel changes View source Failure to understand the need for proper handovers at drop-off and pick-up View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lamarah Grace Scarlett · 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
Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for transport crew to be qualified first aiders
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders ,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of a comprehensive schedule for inspection of transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators ,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory training or forums for transport operators to receive cascaded information
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the passenger assessment test
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement ,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Fragmented access to organisations causing confusion and inconsistency for transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure of transport crew to read and understand patient safety plans
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew ,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct contractually required home visits between passengers and transport crew
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required ,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the local authority of transport crew personnel changes
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew ,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the need for proper handovers at drop-off and pick-up
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” Open source report
13 Sep 2019 Lucia Jayne Stear · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure of public authorities to address tree safety concerns before a fatal event 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
Lucia Jayne Stear · 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
Lucia Jayne Stear was born after a large tree bough fell onto her pregnant mother's car on Arrowe Park Road, causing abdominal trauma. Lucia was delivered by emergency caesarean section, developed multi-organ failure, and died at 15 hours old. The inquest identified inadequate tree management, inspection, training, risk assessment, accountability and communication by Wirral Borough Council, and raised concerns about whether other public authorities faced similar 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure of public authorities to address tree safety concerns before a fatal event
Wider context from the report “Before the inquest Wirral MBC put in place a “Tree Action Plan” which is address the concerns that had been before the court – This is included as an example of what can be achieved when this problem was highlighted by the death of a 15 hour old resident of the Borough.
How many other public authorities are in a similar plight, not having had a fatal tragic event to prompt action?
The Court asks the Rt. Hon. Secretary of State to address this issue nationally and that he advises the court as to what steps he has directed to be taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death.
The Court requests that the LGA brings this matter to the attention of its Local Authority members and that the LGA advises the court as to what steps the organisation has taken to ensure that there is national learning from Lucia’s short life and her tragic avoidable death
” 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 Ask relevant professional networks to share the information with local government officers involved in public parks and environmental services.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
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 Publish the event outcomes, anonymised Section 28 report and good practice on tree management and reducing harm on the LGA website.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
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 up an online event for relevant local authority officers to raise and discuss the review findings.
Verbatim wording from the response “To raise and discuss the findings of your review directly with local authorities, the LGA will set up an event with relevant officers by the end of December 2019, using online/webinar technology to ensure that it is available to a wide range of locations. The outcomes of the event will be made available on the LGA website along with a link to the anonymised Section 28 report and good practice on tree management and reducing the risk of harm. We will ask relevant professional networks of local government officers with an interest in public parks and environment services to share this information with their members.” Source location 2019-0296-Response-by-Local-Government-Association
Open published response
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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 Local Government Association; 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
27 Mar 2019 Ms Donna Williamson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to assign responsibility for repairing and securing doors in privately rented accommodation View source Failure to inform victims promptly when suspects are released on bail View source Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk View source Failure to contact available support services for disabled private tenants View source Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Donna Williamson · 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
Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for repairing and securing doors in privately rented accommodation
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not . Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to inform victims promptly when suspects are released on bail
Wider context from the report “2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk
Wider context from the report “4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge or awareness of their professional and legal duties of disclosure.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to contact available support services for disabled private tenants
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted . Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals
Wider context from the report “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals . She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it.
” Open source report
21 Dec 2018 Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 6 Failure to maintain originally provided fire safety measures, including the kitchen door View source Failure to upgrade existing maisonettes in line with fire safety best-practice guidance View source Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection View source Inadequate design of alternative means of escape from upper floors of maisonettes View source Failure to adopt relevant fire safety guidance for purpose-built blocks of flats View source Absence of functioning fire detection and warning in maisonette halls or landings View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Mihaela Lazar and Ms Dorina Zangari · 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
Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain originally provided fire safety measures, including the kitchen door
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to upgrade existing maisonettes in line with fire safety best-practice guidance
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire .
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient housing-sector awareness of fire risks from inadequate detection and escape protection
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat , in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats'.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Inadequate design of alternative means of escape from upper floors of maisonettes
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to adopt relevant fire safety guidance for purpose-built blocks of flats
Wider context from the report “3. Recommendations
London Fire Brigade believes that stakeholders within the housing sector are not sufficiently aware of the risk of death or injury associated with inadequate fire detection and alarm systems and inadequate protection of the means of escape within the flat, in the event of a fire, presented by this type of premises. Consequently they have not adopted the guidance and recommendations in the Local Government Association publication 'Fire safety in purpose-built blocks of flats' .
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Absence of functioning fire detection and warning in maisonette halls or landings
Wider context from the report “1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.
The problem is threefold:-
i) Undermining of the originally provided fire safety measures i.e. missing kitchen door
ii) Absence of functioning fire detection and warning in the hall or landing , which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and
iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.
There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.
” Open source report
4 Oct 2018 James Ryan McLaren · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 4 Failure to ensure that locked bins can be opened from the inside View source Dark and unlit bin storage areas View source Quiet and isolated bin storage areas View source Failure to secure large commercial or communal domestic bins against entry 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
James Ryan McLaren · 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
James Ryan McLaren was found deceased at a recycling site on 24 December 2017 after he was last seen leaving a nightclub and CCTV showed him walking towards an area containing large commercial waste bins. The report raises concerns about unsecured or inadequately lit bins, the risk of people sheltering inside them, and whether bins can be opened from the inside when locked.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that locked bins can be opened from the inside
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Dark and unlit bin storage areas
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker , and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Quiet and isolated bin storage areas
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to secure large commercial or communal domestic bins against entry
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key , and that to unlock the bins would only take a matter of seconds , and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” Open source report
24 Jul 2017 GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Visitors’ language difficulties and lack of experience with the sea View source Failure to maintain effective public communication about coastal safety View source Lack of formal governance and control of coastal risk management View source Insufficient education and awareness of coastal dangers 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
GUSTAVO SILVA DA CRUZ and 6 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
On 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Visitors’ language difficulties and lack of experience with the sea
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea . The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective public communication about coastal safety
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process ,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of formal governance and control of coastal risk management
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements . Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime , given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient education and awareness of coastal dangers
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea .
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report
29 Sep 2014 Tiya Chetan Chauhan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of awareness of the choking risks of raw jelly cubes during play View source Absence of choking-risk warnings on packets of raw jelly View source Insufficient supervision of raw jelly play with young children 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
Tiya Chetan Chauhan · 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
Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.
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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the choking risks of raw jelly cubes during play
Wider context from the report “(1) That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the especial risks of choking that a cube of raw jelly presents .
” 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 Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-risk warnings on packets of raw jelly
Wider context from the report “(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Local Government Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of raw jelly play with young children
Wider context from the report “(3) That raw jelly cubes may be used in play with young children without sufficient supervision .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations