Concerns raised 8 Lack of a specific water safety safety-equipment policy View source Absence of signage warning of the dangers of deep and fast-flowing water View source Failure to make public activity risk reports readily cross-referenced and accessible to safety inspectors View source Failure to consider provision of equipment for rescuing members of the public in difficulty View source Inadequate annual safety inspection content, format and decision-making criteria View source Lack of a specific water safety risk-assessment policy View source Failure to ensure completion of remedial works identified during safety inspections View source Failure to provide inspectors with guidance for assessing safeguards against deep and fast-flowing water View source See 5 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement a Water Safety Procedure guiding risk assessment and decisions on signage, fencing, information and water-rescue equipment.
View source
Action
Give Project Managers authority to arrange immediate site repairs costing up to £25,000 without awaiting the budget process.
View source
Action
Enhance site-inspection documentation to require pre-inspection checks of prior risk assessments and safety observations reported through Authority systems.
View source
Action
Operate the Public Safety Risk Assessment process to classify sites, prioritise visits proportionately and track timely recommendations.
View source
Action
Maintain a single system for recording, tracking, reporting and reviewing remedial works arising from public-safety inspections.
View source See 2 more actions
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AI-generated summary
Christopher Kapessa · 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
Christopher Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.
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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific water safety safety-equipment policy
Wider context from the report “(2) No specific water safety policy relating to risk assessment or the provision of safety equipment was in place, or is currently in place.
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Absence of signage warning of the dangers of deep and fast-flowing water
Wider context from the report “(4) Inspectors were not provided with any guidance as to how to assess whether members of the public accessing the site should be safeguarded from the risks of deep and fast flowing water, and if so how. No signage was in place to warn of the specific dangers of deep and fast flowing water . No consideration was given as to whether equipment to assist in the rescue of members of the public who may have got into difficulty, such as throw lines, should be provided.
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to make public activity risk reports readily cross-referenced and accessible to safety inspectors
Wider context from the report “(1) The Coal Authority was aware that members of the public used the site for purposes including recreational walking. The Court found that the site was known by children as a site from which to swim, but that this was unknown to the Coal Authority. Nevertheless, Coal Authority documentation was not easily cross referenced or accessible to inspectors to ensure that any reports that might be made with respect to activities by members of the public who might put themselves at risk were available to inspectors when conducting safety inspections .
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to consider provision of equipment for rescuing members of the public in difficulty
Wider context from the report “(4) Inspectors were not provided with any guidance as to how to assess whether members of the public accessing the site should be safeguarded from the risks of deep and fast flowing water, and if so how. No signage was in place to warn of the specific dangers of deep and fast flowing water. No consideration was given as to whether equipment to assist in the rescue of members of the public who may have got into difficulty, such as throw lines, should be provided .
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Inadequate annual safety inspection content, format and decision-making criteria
Wider context from the report “(3) The annual inspections conducted by the Coal Authority were limited in content, unclear in format and identified no clear criteria to be used for the basis of decision making .
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific water safety risk-assessment policy
Wider context from the report “(2) No specific water safety policy relating to risk assessment or the provision of safety equipment was in place, or is currently in place.
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure completion of remedial works identified during safety inspections
Wider context from the report “(5) Remedial work was identified to remedy aspects of the site which rendered it unsafe, but were not carried out . No system appeared to be in place to ensure that such works were carried out following inspection .
” 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 Mining Remediation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide inspectors with guidance for assessing safeguards against deep and fast-flowing water
Wider context from the report “(4) Inspectors were not provided with any guidance as to how to assess whether members of the public accessing the site should be safeguarded from the risks of deep and fast flowing water, and if so how . No signage was in place to warn of the specific dangers of deep and fast flowing water. No consideration was given as to whether equipment to assist in the rescue of members of the public who may have got into difficulty, such as throw lines, should be provided.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Water Safety Procedure guiding risk assessment and decisions on signage, fencing, information and water-rescue equipment.
Verbatim wording from the response “As stated in the letter of the 17 January 2024, the CA was at that time developing a water safety procedure. This sits alongside the CA’s procedure on safe working near water. The CA’s overarching health, safety and wellbeing policy, safe working near water procedure and new Water Safety Procedure are all attached for reference.” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give Project Managers authority to arrange immediate site repairs costing up to £25,000 without awaiting the budget process.
Verbatim wording from the response “There is now a system in place and a process to be followed which ensures that identified works are recorded, notified, remedied and reviewed, with Project Managers (who inspect sites) now having the authority to organise immediate repairs up to the value of £25,000 on their own initiative. The latter reduces the possibility that lower cost repairs, which would include additional fencing for example, can be undertaken more swiftly than if it had to go through the budget process and would remain in the immediate oversight of the inspector.” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance site-inspection documentation to require pre-inspection checks of prior risk assessments and safety observations reported through Authority systems.
Verbatim wording from the response “At the time of the incident there existed and had existed for many years, a 24-hour hazard report line which enabled such reports to be received, logged and acted upon and there is no evidence, as became clear during the inquest, that such reports were received by the CA. In addition to this any observations made by CA staff (outside of formal inspections) or reported by the public through other channels are recorded through the CA’s online Health and Safety portal.” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Public Safety Risk Assessment process to classify sites, prioritise visits proportionately and track timely recommendations.
Verbatim wording from the response “As outlined in ████████ letter of the 17th January, a new Public Safety Risk Assessment (PSRA) process was introduced during July 2020. The PSRA, its associated guidance and the e-learning package, was developed by the Authority’s Safety, Health & Environment (SHE) team in collaboration with the Environment Agency and with good practice adapted to meet the specific needs of the Authority.” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a single system for recording, tracking, reporting and reviewing remedial works arising from public-safety inspections.
Verbatim wording from the response “This concern has been addressed through the reviewed Public Safety Risk Assessment process as mentioned above and in Paul Frammingham’s letter of the 17 January 2024 where in addition to a description of the new Public Safety Risk Assessment process, he states,” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing hazard-reporting and online safety systems are considered sufficient to record, action and provide relevant public safety information to inspectors.
Verbatim wording from the response “At the time of the incident there existed and had existed for many years, a 24-hour hazard report line which enabled such reports to be received, logged and acted upon and there is no evidence, as became clear during the inquest, that such reports were received by the CA. In addition to this any observations made by CA staff (outside of formal inspections) or reported by the public through other channels are recorded through the CA’s online Health and Safety portal.” Source location Response from Browne Jacobson
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Blanket installation of public rescue equipment is not considered appropriate because of vandalism, theft, misuse, limited effectiveness and potential encouragement of water access.
Verbatim wording from the response “It is, of course, important that any such procedure provides guidance on assessing the viability of the provision of such equipment and does not simply create a blanket policy requiring the same.” Source location Response from Browne Jacobson
Open published response
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Request correction
Addressed to Coal Authority, now represented here by Mining Remediation Authority.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations