Recipient

National Health Service

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First report 20 Apr 2023•Latest report 20 Apr 2023

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from National Health Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cumbria

    AI-generated summary

    CHESTER ALAN STANLEY MOSSOP · 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

    Chester was a nine-month-old baby who drowned after being left alone in a bath seat that became unfixed. He sustained a severe brain injury and died on 3 June 2022. The principal concern was that bath seats may create a false sense of security, despite not being safety devices, and that national advice about their risks and safe use may not be consistently provided.

    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 National Health Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national provision of safe bath-seat-use advice to healthcare professionals and parents or carers

    Wider context from the report

    “I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents. The use of bath seats is of concern to RoSPA. Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits. I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices. ”
    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 National Health Service; that does not assign responsibility.

    PFD Monitor interpretation

    Bath seats creating a false sense of security despite not being safety devices

    Wider context from the report

    “I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents. The use of bath seats is of concern to RoSPA. Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits. I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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

Data last updated 7 September 2026