Concerns raised 12 Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft View source Lack of proper protection for passengers and crew from impact and vibration hazards View source Non-uniform risk management for high-speed rides View source Confusing and inconsistent requirements and guidance for small-craft operators View source Insufficient crewing for lookout and skipper workload control View source Delays in revising codes of practice for high-speed craft View source Loss of situational awareness during RIB operations View source Inadequate seating and collision-impact mitigation in RIBs View source Inadequate forward visibility from passenger-carrying RIBs View source Failure to ensure timely and comprehensive review of MAIB recommendations View source Unavailability of AIS capability for monitoring RIB operations View source Excessive piloting workload during high-speed RIB operations View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Jane LEWIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emily Jane Lewis, aged 15, died at Southampton General Hospital on 22 August 2020 after the high-speed RIB on which she was a passenger collided with a buoy, projecting her into a handhold and causing fatal injuries. The principal concerns included the workload and situational awareness of a lone skipper, inadequate forward visibility and passenger protection, shortcomings in seating and handrail design, insufficient risk assessment and safety management, and confusing or inconsistent regulation of high-speed RIB experience rides.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of proper protection for passengers and crew from impact and vibration hazards
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Non-uniform risk management for high-speed rides
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides .
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Confusing and inconsistent requirements and guidance for small-craft operators
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient crewing for lookout and skipper workload control
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Delays in revising codes of practice for high-speed craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back : the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond . The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Loss of situational awareness during RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate seating and collision-impact mitigation in RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions , noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate forward visibility from passenger-carrying RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and comprehensive review of MAIB recommendations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AIS capability for monitoring RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS) . There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Excessive piloting workload during high-speed RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Commission and complete an anthropometric assessment of safety requirements for small high-speed passenger craft, including seating, handholds and restraints.
Verbatim wording from the response “Furthermore, the MCA has begun the procurement process to commission an anthropometric assessment of the design and operational requirements for small high-speed passenger craft safety and the protection of passengers and crew provided by the craft with respect to whole-body vibration and sudden decelerations in the event of a horizontal impact. This will require, among other things; assessment of the full anthropometric range of passengers and crew, the operational profile of the vessels, including the range of speeds, as well as crash protection and general protection of the seating arrangements including the design and use of handholds and restraints” Source location Response from Maritime and Coastguard Agency
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 Advance legislation and an updated Sport or Pleasure Vessel Code through consultation and Parliamentary processes.
Verbatim wording from the response “Staff at MCA have prioritised work to replace the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280(M) (Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards). We are focussing on bringing forward new legislation and an updated Code of Practice for Small Vessels in Commercial Use for Sport or Pleasure (the “Sport or Pleasure Vessel Code”) as soon as practical, in line with the required consultation and Parliamentary processes.” Source location Response from Maritime and Coastguard Agency
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interim measures to manage high-speed RIB experience-ride risks cannot be implemented before the revised Sport or Pleasure Vessel Code takes effect.
Verbatim wording from the response “is currently at the midpoint of a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted however, that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect.” Source location Response from Maritime and Coastguard Agency
Open published response
Concerns raised 2 Failure to respond adequately to issues identified through breakdowns requiring rescue at sea View source Failure to establish and apply a clear threshold for full stability assessments after significant vessel modifications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ross Stephen Ballatine and 2 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
Ross Stephen Ballatine, Carl Stephen McGrath and Alan Wallace Minard died from immersion/drowning after the fishing vessel Nicola Faith capsized off the coast of North Wales on 27 January 2021. The principal concerns were that the Maritime and Coastguard Agency had not established or applied a clear threshold for requiring full stability assessments after significant vessel modifications, relied too heavily on the skipper's assurances and informal visual assessments, and did not give sufficient weight to earlier rescue incidents.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to respond adequately to issues identified through breakdowns requiring rescue at sea
Wider context from the report “Although I was somewhat reassured to learn that the relevant Regulations have been revised and strengthened since these events, I am concerned that in this case (and, therefore, possibly in other cases) the Agency did not establish or apply a clear threshold in determining the need for a full stability assessment to be performed following significant modifications to the vessel. Too much reliance was placed on: (1) reassurances offered by the skipper of the vessel in relation to his appreciation of risk and/or his operational intentions (notably about the size and distribution of the load); and (2) informal visual assessments of the impact of the modifications which were undertaken whilst the vessel was in dock and was not under loaded conditions.
In addition, insufficient concern arose from the issues identified on the two occasions when Holyhead Coastguard advised the Agency of the need to rescue the vessel following breakdowns at sea .
I am concerned that other vessels (whether or a similar size or otherwise) may be operating, which have been modified since the issue of the original safety certificate and which require a full stability assessment before their operational safety can be properly evaluated.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and apply a clear threshold for full stability assessments after significant vessel modifications
Wider context from the report “Although I was somewhat reassured to learn that the relevant Regulations have been revised and strengthened since these events, I am concerned that in this case (and, therefore, possibly in other cases) the Agency did not establish or apply a clear threshold in determining the need for a full stability assessment to be performed following significant modifications to the vessel . Too much reliance was placed on: (1) reassurances offered by the skipper of the vessel in relation to his appreciation of risk and/or his operational intentions (notably about the size and distribution of the load); and (2) informal visual assessments of the impact of the modifications which were undertaken whilst the vessel was in dock and was not under loaded conditions .
In addition, insufficient concern arose from the issues identified on the two occasions when Holyhead Coastguard advised the Agency of the need to rescue the vessel following breakdowns at sea.
I am concerned that other vessels (whether or a similar size or otherwise) may be operating, which have been modified since the issue of the original safety certificate and which require a full stability assessment before their operational safety can be properly evaluated .
” 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 Update surveyor guidance for investigating vessel modifications to include assessing their impact on stability.
Verbatim wording from the response “Further, in September 2021, the MCA has updated its guidance to Surveyors in investigation of modifications MSIS27 Chapter 1 which includes an assessment of the impact on stability.” Source location Response from Maritime & Coastguard Agency
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 Implement strengthened stability requirements for fishing vessels under 15 metres, including stability records and confirmation during five-year certificate renewals.
Verbatim wording from the response “The Code of Practice for the Safety of Small Fishing Vessels of less than 15 metres length overall MSN1871 Amendment 2 came into force on 6 September 2021.” Source location Response from Maritime & Coastguard Agency
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 Conduct at least 250 ad hoc vessel inspections annually, considering vessel modifications and stability.
Verbatim wording from the response “The Coroner is aware the MCA conducts ad hoc inspections. These commenced in 2021 as concentrated inspection campaigns and now form part of MCA's usual Surveying business. A minimum of 250 vessels are inspected on an ad hoc basis per year and the inspections consider vessel modifications and stability.” Source location Response from Maritime & Coastguard Agency
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 Identify vessels not yet inspected and contact them directly about the urgent safety bulletin.
Verbatim wording from the response “2,734 vessels currently remain to be inspected against this Code as part of the 5 yearly inspection regime by 5 September 2026.” Source location Response from Maritime & Coastguard Agency
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 and disseminate an urgent safety bulletin explaining modification-reporting and stability-assessment requirements to the fishing industry.
Verbatim wording from the response “However, in order to go beyond the ad hoc inspections and seek to capture any vessels of less than 15 metres length overall within the 2,734 which potentially may not be due an inspection until September 2026, but may have made modifications which have not been notified to the MCA, the MCA published an Urgent Safety bulletin on 4 September 2023 Safety bulletin 32 - Vessel modifications increasing risk” Source location Response from Maritime & Coastguard Agency
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 Require follow-up inspections after fatality, serious injury, serious damage or major mechanical breakdown, including review of prior inspections and current Code compliance.
Verbatim wording from the response “In response to the Coroner's comment regarding insufficient concern having been given following the two breakdowns of the Nicola Faith at sea, the MCA had published MSIS27 Annex 23 in April 2020.” Source location Response from Maritime & Coastguard Agency
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reviewing 2,734 vessel files would require extensive work and still would not identify vessels whose modifications were unnotified.
Verbatim wording from the response “To identify vessels that may have informed MCA prior to 6 September 2021 of modifications they intend to carry out (which may or may not have been completed) would require an extensive review of all files relating to those 2,734 vessels. This process would also not identify any vessels which may have carried out modifications without notifying MCA.” Source location Response from Maritime & Coastguard Agency
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at 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
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” Open source report
Concerns raised 3 Failure to mitigate shortfalls in lifeguard service with additional emergency service resource View source Lack of a published public plan for managing reduced lifeguard service View source Lack of adequate coastguard cover around the Cornish coastline View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony John 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
Anthony John Williamson, an experienced kayaker, departed from Trebarwith Strand in a group and was later recovered from the sea after coming out of his kayak in heavy swells at Cambeath Point. He could not be resuscitated, and a final post-mortem cause of death was awaited. Concerns were raised about the adequacy of coastguard cover during the Coronavirus pandemic and whether reduced lifeguard services were being mitigated by additional emergency-service resources.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to mitigate shortfalls in lifeguard service with additional emergency service resource
Wider context from the report “It is not clear to me whether there were lifeguards on duty at Trebarwith Strand or elsewhere in north Cornwall at the time of this incident. My further, current cause for concern is that, where there may be a reduced lifeguard service , how any shortfall may be mitigated by additional coastguard or other emergency service resource . Is there a published plan giving notice to the public on how the situation is being managed?
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a published public plan for managing reduced lifeguard service
Wider context from the report “It is not clear to me whether there were lifeguards on duty at Trebarwith Strand or elsewhere in north Cornwall at the time of this incident. My further, current cause for concern is that, where there may be a reduced lifeguard service, how any shortfall may be mitigated by additional coastguard or other emergency service resource. Is there a published plan giving notice to the public on how the situation is being managed?
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate coastguard cover around the Cornish coastline
Wider context from the report “My current cause for concern is to ensure that there is an adequate level of coastguard cover around the Cornish coastline . To what extent, if at all, has the Coronavirus pandemic caused a reduction in the level of coastguard protection in comparison to 2019? If there has been a reduction in the level of cover, how has this been mitigated? Is the amount of cover now at an acceptable level?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work closely with Surf Life Saving GB on beach safety services and additional coastal surveillance.
Verbatim wording from the response “HM Coastguard have been working closely since the start of the pandemic with Surf Life Saving GB (SLSGB) who run a programme of Beach Safety services that range from the full lifeguarding provision to providing the public with advice about how to keep safe, by raising awareness of the risks. The SLSGB volunteers are providing a service in some areas in the evenings after RNLI/other lifeguards have left for the day as an” Source location 2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
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 Deploy additional Coastguard vehicle patrols to high-risk coastal areas for summer surveillance and rapid search-and-rescue response.
Verbatim wording from the response “To help provide extra surveillance as a Category 1 responder throughout the busy summer season, we have been deploying more HM Coastguard vehicle patrols to high risk areas to keep a look out for any incidents at the coast enabling a swift response to search and rescue if required.” Source location 2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
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 Implement and maintain COVID-secure Coastguard response arrangements and appropriate search-and-rescue procedures.
Verbatim wording from the response “In response to your causes for concern, I can reassure you that since the beginning of the Coronavirus pandemic, there has been no reduction in the service HM Coastguard provide for search and rescue purposes. Our network of Coastguard Operations Centres maintained emergency provision for the UK coast throughout national lockdown and we continue to do so. COVID secure environments are in place both in the control rooms and for our volunteer Coastguard Rescue Teams when responding to incidents. These arrangements are continually reviewed in line with updated guidance and are closely monitored. Working with contractors who provide the Search and Rescue Helicopter capability for UK Search and Rescue, we have ensured appropriate procedures have been implemented and followed, linking with our own clinical Governance Board requirements.” Source location 2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RNLI is responsible for addressing concerns about its risk-based lifeguard deployment during the pandemic.
Verbatim wording from the response “I am aware that because of the pandemic a risk-based approach has been taken by the RNLI to the deployment of lifeguards. However, the RNLI who provide most lifeguard services in the UK will be able to address this point in more detail. The RNLI maintained communication and shared plans throughout this transition period with HMCG regarding the provision of a lifeguard service and their arrangements with Local Authorities.” Source location 2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There has been no reduction in HM Coastguard’s search and rescue service during the pandemic.
Verbatim wording from the response “In response to your causes for concern, I can reassure you that since the beginning of the Coronavirus pandemic, there has been no reduction in the service HM Coastguard provide for search and rescue purposes. Our network of Coastguard Operations Centres maintained emergency provision for the UK coast throughout national lockdown and we continue to do so. COVID secure environments are in place both in the control rooms and for our volunteer Coastguard Rescue Teams when responding to incidents. These arrangements are continually reviewed in line with updated guidance and are closely monitored. Working with contractors who provide the Search and Rescue Helicopter capability for UK Search and Rescue, we have ensured appropriate procedures have been implemented and followed, linking with our own clinical Governance Board requirements.” Source location 2020-0153-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
Concerns raised 3 Lack of publicly available information on beach lifeguard cover View source Lack of a published plan for mitigating lifeguard-cover shortfalls View source Reduced or absent lifeguard cover on Cornish beaches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jan KLEMPAR · 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
Jan Klempar was swimming in the sea at Porthcurno in west Cornwall, where no lifeguards were on duty despite the beach ordinarily having lifeguard cover. The concerns raised relate to reduced or absent lifeguard cover on Cornish beaches, public information about coverage, and plans to mitigate shortfalls through additional emergency resources.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly available information on beach lifeguard cover
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach .
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a published plan for mitigating lifeguard-cover shortfalls
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach.
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Reduced or absent lifeguard cover on Cornish beaches
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season ? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019 ? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach.
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Surf Life Saving GB on additional beach safety services and public risk-awareness provision.
Verbatim wording from the response “HM Coastguard have been working closely since the start of the pandemic with Surf Life Saving GB (SLSGB) who run a programme of Beach Safety services that range from the full lifeguarding provision to providing the public with advice about how to keep safe, by raising awareness of the risks. The SLSGB volunteers are providing a service in some areas in the evenings after RNLI/other lifeguards have left for the day as an additional facility for the Coastguard (RNLI lifeguards normally work from 10am to 6pm and only at certain times of the year).” Source location 2020-0152-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
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 Deploy additional HM Coastguard vehicle patrols to high-risk coastal areas during the busy summer season.
Verbatim wording from the response “To help provide extra surveillance as a Category 1 responder throughout the busy summer season, we have been deploying more HM Coastguard vehicle patrols to high risk areas to keep a look out for any incidents at the coast enabling a swift response to search and rescue if required.” Source location 2020-0152-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Beach lifeguard provision is outside the respondent’s statutory and specific responsibilities for beach safety.
Verbatim wording from the response “The provision of lifeguards on beaches is not the responsibility of the MCA as we do not have any statutory or specific responsibilities for beach safety; RNLI are the main provider of beach lifeguards on the coast. Beach Lifeguard Units are classified by the HM Coastguard as additional facilities that provide a service for the local council or landowner. We can ask them to assist with the response to an incident, we cannot task them as we would for a RNLI lifeboat (lifeboats are a declared facility). In fact, lifeguards often find themselves in a position to inform the Coastguard operations centres of an incident, where additional assistance is required.” Source location 2020-0152-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Landowners, chiefly local councils and the National Trust, are responsible for beach facilities and safety measures.
Verbatim wording from the response “Information about beaches, the facilities available and safety measures are the responsibility of the landowners, the majority of which are local councils and the National Trust. Details about the facilities available and safety measures in place can be found on most beach owners’ websites.” Source location 2020-0152-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RNLI is the main provider of beach lifeguards and can provide detailed information about the lifeguarding approach.
Verbatim wording from the response “The provision of lifeguards on beaches is not the responsibility of the MCA as we do not have any statutory or specific responsibilities for beach safety; RNLI are the main provider of beach lifeguards on the coast. Beach Lifeguard Units are classified by the HM Coastguard as additional facilities that provide a service for the local council or landowner. We can ask them to assist with the response to an incident, we cannot task them as we would for a RNLI lifeboat (lifeboats are a declared facility). In fact, lifeguards often find themselves in a position to inform the Coastguard operations centres of an incident, where additional assistance is required.” Source location 2020-0152-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
Concerns raised 2 Lack of publicly available information on planned lifeguard patrol locations and timing View source Unavailability of professional lifeguard cover on Cornwall beaches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Louisa Davey died after a pleasure craft capsized off the north Cornish coast, trapping her underneath, and Michael Pender died after being rescued from the sea off Treyarnon Bay, apparently having been caught in a rip current. The principal concern was that there was no lifeguard cover on any Cornish beach that day, with uncertainty about when professional lifeguard services would resume and concern about further loss of life.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly available information on planned lifeguard patrol locations and timing
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Unavailability of professional lifeguard cover on Cornwall beaches
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Beach safety is outside the agency’s statutory or specific responsibilities.
Verbatim wording from the response “The Department for Transport and the Maritime & Coastguard Agency have an interest in maritime safety generally because we want to see fewer accidents and less demand on the emergency services that we coordinate to respond to search and rescue missions. That is why we promote initiatives such as the annual Maritime Safety Week alongside partner organisations and we use our social media and other channels to communicate safety campaigns and messages. We do not have any statutory or specific responsibilities for beach safety.” Source location 2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lifeguarding services cannot provide an absolute guarantee of beach safety because they are limited in coverage, hours and seasonality.
Verbatim wording from the response “Fundamentally and ultimately, however, people have a personal responsibility for their own safety in and around water and on beaches. Landowners, local authorities and others can provide safety information including signage and public rescue equipment, but it is individuals taking responsibility for their own safety and actions that will keep most people safe. Even where beach owners carry out a risk assessment and conclude that they can support safety by providing a lifeguarding service, whether from the RNLI or another provider, those services will not operate 24 hours a day and always cover just a limited area of each beach. Deployment will also be seasonal to take account of the times of year when the risk is judged to be at its highest. The provision of a lifeguarding service is not, and can never be, an absolute guarantee of safety.” Source location 2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
Concerns raised 2 Unavailability of public information on planned beach patrol locations and timing View source Lack of professional lifeguard cover on Cornwall’s beaches 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
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Davey, aged 17, was trapped under a capsized pleasure craft near Padstow and could not be resuscitated. On the same day, Michael Pender, aged 63, was rescued after apparently being caught in a rip current while swimming off Treyarnon Bay, but could not be resuscitated. The principal concern was that no Cornish beach had lifeguard cover that day and that beaches remained unguarded, with a fear of further loss of life until professional lifeguard services returned.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Unavailability of public information on planned beach patrol locations and timing
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of professional lifeguard cover on Cornwall’s beaches
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” Open source report
19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kurt Cochran and 5 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding attacks .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to provide revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 Reviewed the need for guidance on removing unconscious persons or bodies from navigable waterways through research and stakeholder discussions.
Verbatim wording from the response “Following the inquest into the death of Andre[a] Cristea, which concluded in October 2018, HH Judge Mark Lucraft QC recommended that the Maritime and Coastguard Agency (MCA) considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water to those operating on navigable rivers and canals.” Source location 2018-0304-Response-by-Maritime-Coastguard-Agency
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing RYA emergency training and Canal and River Trust safety information are sufficient for leisure boat users on navigable waterways.
Verbatim wording from the response “Taking the points above into consideration, we believe that sufficient guidance already exists in the public domain for those operating commercial vessels on navigable rivers and canals through the Inland Waters Small Passenger Boat Code, which is published by AINA¹, and available on gov.uk². For leisure boat users, training that covers emergency situations is available from the RYA³ and the Canals and Rivers Trust provides information for boaters to keep safe⁴.” Source location 2018-0304-Response-by-Maritime-Coastguard-Agency
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Inland Waters Small Passenger Boat Code guidance is sufficient for commercial vessel operators recovering unconscious persons or bodies from navigable waterways.
Verbatim wording from the response “Taking the points above into consideration, we believe that sufficient guidance already exists in the public domain for those operating commercial vessels on navigable rivers and canals through the Inland Waters Small Passenger Boat Code, which is published by AINA¹, and available on gov.uk². For leisure boat users, training that covers emergency situations is available from the RYA³ and the Canals and Rivers Trust provides information for boaters to keep safe⁴.” Source location 2018-0304-Response-by-Maritime-Coastguard-Agency
Open published response
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.
×
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 Maritime and Coastguard Agency; 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 Maritime and Coastguard Agency; 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 Maritime and Coastguard Agency; 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 Maritime and Coastguard Agency; 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
×
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 Nominate coastguard officers as National Drowning Prevention Officers targeting high-risk activities including diving, motorboating and swimming.
Verbatim wording from the response “In addition, Her Majesty’s Coastguard can call on its 3,500 volunteer Coastguard Rescue Officers based in local communities on the coast to provide engaging safety talks and demonstrations, and this is something MCA will be looking to do more of. The MCA and I are also keen to extend those opportunities to communities in our bigger cities so that people from urban backgrounds are better prepared for the risks they may encounter when they venture to the seaside. The Agency has recently nominated a number of coastguard officers to act as National Drowning Prevention Officers to target particular high - risk activities such as diving, motorboating and swimming.” Source location Response from Department for Transport
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 Operate the Coastal Safety mini-website providing consolidated safety guidance for families and casual beach visitors.
Verbatim wording from the response “The Agency is already actively involved in some prevention work, regularly advocating safety messages and campaigns at targeted audiences. For example, in response to recent research indicating a growing public appetite for online guidance, the MCA launched this summer a Coastal Safety mini-website¹ which distils simple safety information in one place, for the benefit of families and casual beach visitors.” Source location Response from Department for Transport
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 Fund an independent review of national beach-safety risk management and drowning prevention, including international and cross-sector comparisons.
Verbatim wording from the response “A current gap in risk management has been identified as a national issue and has been recognised through MCA’s work with the NWSF. Target 2 of the Strategy states that: ‘Every community with water safety risks should have a risk assessment and water safety plan in place’. Presently the risk management of water safety risks is conducted on an ad hoc basis and takes many different forms. To gain an understanding of the national situation, the MCA will fund an independent review of the current system of risk management pertaining to beach safety and the prevention of drowning. This will include research into how the UK compares to other leading nations such as Australia, New Zealand, Canada, Netherlands and Germany. The review will also compare other similar risk themes such as road traffic or fire harm, for the prevention of injury and will report by end of July 2018.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the RNLI on coastal risk management through visits to landowners about local risks and targeted safety interventions.
Verbatim wording from the response “The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Landowners, often local authorities, are responsible for assessing coastline and beach risks and determining appropriate safety interventions.
Verbatim wording from the response “There are more than 11,500 miles of coast around the United Kingdom, and the Government is opening coastal paths to support public health, fitness and wellbeing, whilst encouraging people to enjoy this country’s coast and beaches. It is the responsibility of landowners (in many cases the local authority) who have a duty of care to assess the safety risks associated with their coastlines and beaches and to determine whether they need to put in place safety interventions. This may include safety signage and/or, where appropriate, professional lifeguarding services provided by the Royal National Lifeboat Institution (RNLI), the Royal Life Saving Society (RLSS) and other organisations.” Source location Response from Department for Transport
Open published response
2 Dec 2016 Joshua Harry Smith · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 7 Searches being stood down without confirming reported safety information View source Delay in deploying the Hazardous Area Response Team to a hazardous-area incident View source Failure to recognise location information from 999 calls View source Unclear multi-agency command control and co-ordination View source Failure to identify location from mobile 999 calls View source Failure to immediately alert police and other emergency services from 999 call information View source Failure to provide police control with essential incident information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua Harry Smith · 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
Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Searches being stood down without confirming reported safety information
Wider context from the report “The search for Joshua was briefly stood down after a North East Ambulance call to Joshua’s father indicated that Joshua was at home in his bedroom, without waiting for ████████ to check and confirm whether Joshua was in fact in his bedroom.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Delay in deploying the Hazardous Area Response Team to a hazardous-area incident
Wider context from the report “Joshua had explained in his 999 call that he was below cliffs having fallen, was injured and that an ambulance would not be able to reach him. The Hazardous Area Response Team of North East Ambulance was not deployed to the incident until approximately 3 a.m. arriving at the scene under an hour later and were 1.5 miles away from the incident at the time Joshua was swept out to sea by action of the waves.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise location information from 999 calls
Wider context from the report “The search for Joshua continued at Berwick Holiday Park (on the north side of the River Tweed and the town of Berwick-upon-Tweed) as a result of his location at Spittal Beach not being recognised from his 999 call .
After Joshua’s phone call was ‘listened back’ it was observed that he had described his location as Spittal, at the bottom of a cliff, near Spittal beach.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Unclear multi-agency command control and co-ordination
Wider context from the report “The circumstances of the death showed that although there were examples of good co-operation and effort among the emergency services, overall command, control and co-ordination were unclear and JESIP was not followed.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to identify location from mobile 999 calls
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately alert police and other emergency services from 999 call information
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police control with essential incident information
Wider context from the report “Two Police Officers on Berwick Town Centre duties (which is north of the River Tweed) were asked in the street by paramedics for assistance in locating Joshua, and while paramedics went to look for Joshua on the north side of Berwick near the Holiday Park and cliffs, the police officers travelled to Spittal looking for Joshua although they had no name or further details at that time . A brief search of Spittal beach near to the cliffs by Police Officers was unsuccessful, before they returned to Town Centre duties. A report to Police Control was not made at that time.
” 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 Issue updated operational guidance addressing the identified emergency communications limitation.
Verbatim wording from the response “Regarding the matters of concern, Her Majesty’s Coastguard (HMCG) has noted the North East Ambulance Communications system limitation surrounding the inability to ‘play back’ live 999 calls. We have also reviewed our own systems, and updated guidance has been issued and training packages modified.” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide JESIP training for Coastguard tactical commanders, strategic commanders and all officers through courses and basic-training modules.
Verbatim wording from the response “As to the issue of Joint Emergency Service Interoperability (JESIP), we can report significant progress has been achieved in the wake of this incident. All Coastguard tactical commanders attend JESIP courses, and strategic level commanders attend the Multi-Agency ‘Gold’ course, known as ‘MAGIC’. Every Coastguard officer completes online training in JESIP as part of their basic training.” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
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 Modify training packages to reflect the updated operational guidance.
Verbatim wording from the response “Regarding the matters of concern, Her Majesty’s Coastguard (HMCG) has noted the North East Ambulance Communications system limitation surrounding the inability to ‘play back’ live 999 calls. We have also reviewed our own systems, and updated guidance has been issued and training packages modified.” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
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 Conduct exercises and joint planning with emergency-service partners to improve mutual familiarity and cooperation.
Verbatim wording from the response “Also since early 2016, HMCG has established an additional 18 full-time senior officer roles throughout the UK’s coastal regions to further enhance its capability and engagement within Local Resilience Fora and with emergency service partners. We” Source location 2016-0599-Response-by-Maritime-Coastguard-Agency
Open published response
Concerns raised 1 Lack of mandatory wearing of personal flotation devices on fishing vessel decks at sea 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
Gareth Willington and Daniel James Willington · 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
Gareth Willington and his son Daniel James Willington went out on their fishing boat on 28 April 2016. Gareth was recovered from the sea and pronounced dead at hospital, while Daniel’s body was not recovered; an MAIB report concluded that both men went overboard after Daniel became entangled in a rope and Gareth went to assist him. Neither man was wearing a personal flotation device, and the substantive concern was that wearing such devices on fishing vessels’ working decks was not mandatory.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory wearing of personal flotation devices on fishing vessel decks at sea
Wider context from the report “That the wearing of personal flotation devices whilst on deck is not mandatory. The report from the MAIB in their report no 22/2016 states “the benefits of wearing PFDs on the exposed decks of fishing vessels are incontrovertible”. Legislation requiring the compulsory wearing of personal flotation devices on the working decks of fishing vessels while at sea would lead to a reduction in the number of deaths at sea.
” Open source report
4 Nov 2014 Rebecca Jodie CURTIS-SMALL · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 2 Failure to provide signage warning of specific riptide hazards under varying tide conditions View source Failure to ensure easily visible appropriate signage at each beach entrance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebecca Jodie CURTIS-SMALL · 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
Rebecca Jodie CURTIS-SMALL was caught by a rip tide while swimming with her family at Croyde Bay on 31 December 2013. She was found after a search, taken to hospital, and died from drowning and hypothermia; concerns related to the visibility and specificity of beach signage warning about rip-tide hazards.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to provide signage warning of specific riptide hazards under varying tide conditions
Wider context from the report “1. That the appropriate signage is displayed in a way that can easily be seen on each of the entrances to the beach.
2. Whether the sign could refer to any specific riptide hazards known of at the beach in order to warn members of the public using the beach at different times of the year and different states of the tide, that rip tides would be more hazardous .
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure easily visible appropriate signage at each beach entrance
Wider context from the report “1. That the appropriate signage is displayed in a way that can easily be seen on each of the entrances to the beach .
2. Whether the sign could refer to any specific riptide hazards known of at the beach in order to warn members of the public using the beach at different times of the year and different states of the tide, that rip tides would be more hazardous.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The placement, content and maintenance of Croyde Beach signage are outside the MCA’s responsibility.
Verbatim wording from the response “The exact placement, content and maintenance of the signage at Croyde Beach is not the responsibility of the MCA or the RNLI and I am unable to comment on the historical placement arrangements. With regard to evidence that the signs on this particular beach could have been better placed I do understand that the exact placement of signage is often a compromise due to demands of requirements by planning and local authorities, beach owners or operators or environmental, financial or other constraints.” Source location 2014-0483-Response-by-Maritime-Coastguard-Agency
Open published response
27 May 2014 Gerardo Abadilla Tongobanua · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices View source Lack of requirements to assess rescue boat lifting davits, winches and fall wires as a system 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
Gerardo Abadilla Tongobanua · 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 7 February 2011, Gerardo Abadilla Tongobanua fell 29 metres during a fast rescue boat drill onboard the MV Tombarra while it was docked at Royal Portbury Dock, Bristol, after the fall wire snapped. The concerns identified were that the winch motor could overstress the fall wire and that the failed electronic switch did not stop the motor, while the relevant code and standard did not adequately specify system design or safety-device requirements.
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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices
Wider context from the report “2. An electronic switch, fitted to the rescue boat davit onboard Tombarra, failed to operate and stop the winch motor. The LSA Code refers to ‘safety devices’ fitted to the davits which will automatically cut off the winch power to prevent overstressing of components. This is reflected in the international standard ISO 15516 “Ships and marine technology—launching appliances for davit-launched lifeboats”. However, neither the Code nor the standard specify the number, definition or performance of the ‘safety devices’ fitted. Consequently, manufacturers have little guidance in these areas compared to manufacturers of industrial machinery
” 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 Maritime and Coastguard Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements to assess rescue boat lifting davits, winches and fall wires as a system
Wider context from the report “1. The fall wire of MV Tombarra’s rescue boat failed because the winch electric motor was capable of easily overstressing the fall wire to the point of failure. There is currently no requirement within the Life-Saving Appliances (LSA) Code to consider design of the rescue boat lifting davit, winch and fall wire, as a ‘system’ when assessing the suitability of the forces and loads applied. The Code infers that ‘overstressing’ of the falls or davits could occur.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations