9 Jan 2024 Andrew James Rees · Prevention of Future Deaths report Avon
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Concerns raised 2 Insufficiency of visual inspection for identifying deteriorating rescue chains View source Lack of formal assessment of changes in use triggering Port Marine Risk Assessment review View source
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. 2
Action
Conduct annual risk assessments and review the assessment when specified trigger events, including changes of use, occur.
View source
Action
Update the Port Marine, Portishead risk assessment to formalize annual assessments and reviews triggered by specified changes, including change of use.
View source
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AI-generated summary
Andrew James Rees · 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
Andrew James Rees consumed very high levels of alcohol before walking home severely intoxicated alongside Portishead Marina, where his body was later retrieved. He died due to immersion in water; concerns included a broken rescue chain that visual inspections had not identified and the absence of an apparent formal assessment of changes in use relevant to the marina risk assessment.
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× 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 North Somerset Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiency of visual inspection for identifying deteriorating rescue chains
Wider context from the report “(1) Boatfolk Marinas Ltd only
In evidence it was identified that, in the vicinity of where the deceased was retrieved from the water, the rescue chain on the wall of the marina was broken and that the system of visual inspection in place for Boatfolk Marinas Ltd had not identified this. Whilst a monthly, documented visual inspection has been introduced it is a concern that visual inspection alone may be insufficient to identify the risk of a deteriorating chain .
” 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 North Somerset Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal assessment of changes in use triggering Port Marine Risk Assessment review
Wider context from the report “(2) North Somerset Council only
During the course of evidence one of the triggers to generate a review of the Port Marine, Portishead Risk Assessment by North Somerset Council was stated to be a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent .
” 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 Conduct annual risk assessments and review the assessment when specified trigger events, including changes of use, occur.
Verbatim wording from the response “8. The latest risk assessment which was put forward at the inquest hearing in evidence had a review date of February 2024. This date was set to allow North Somerset Council to reflect on any aspects of the inquest evidence and taking into consideration that until disclosure of the inquest bundle took place, just days before the commencement of the inquest on 9 January 2024, North Somerset Council had no indication of the actual facts surrounding this incident. In line with the written risk assessment and the evidence given at the inquest itself this risk assessment has been further reviewed and we attach a copy of it to this letter. This shows that there will be an annual risk assessment and that risk assessment review will be triggered in a number of circumstances, including any change of use of the area.” Source location Response from Clyde&Co
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 Update the Port Marine, Portishead risk assessment to formalize annual assessments and reviews triggered by specified changes, including change of use.
Verbatim wording from the response “8. The latest risk assessment which was put forward at the inquest hearing in evidence had a review date of February 2024. This date was set to allow North Somerset Council to reflect on any aspects of the inquest evidence and taking into consideration that until disclosure of the inquest bundle took place, just days before the commencement of the inquest on 9 January 2024, North Somerset Council had no indication of the actual facts surrounding this incident. In line with the written risk assessment and the evidence given at the inquest itself this risk assessment has been further reviewed and we attach a copy of it to this letter. This shows that there will be an annual risk assessment and that risk assessment review will be triggered in a number of circumstances, including any change of use of the area.” Source location Response from Clyde&Co
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 The evidence does not show that change of use lacked formal assessment or that current circumstances create an ongoing risk of further deaths.
Verbatim wording from the response “‘During the course of evidence one of the triggers to generate a review of the Port Marine, Portishead Risk Assessment by North Somerset Council was stated to be a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent.’” Source location Response from Clyde&Co
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 risk assessments, audits and review triggers, including annual review and changes of use or incidents, are considered sufficient to manage the area’s risk.
Verbatim wording from the response “1. There was considerable evidence about previous risk assessments, reviews and audits of the area between at least 2008 and 2023, with copies of the same provided to the court and explained, where necessary, in lengthy statements and oral evidence. Those assessments had clearly taken into account present and proposed use of the area and demonstrated a formal measure of change of use.” Source location Response from Clyde&Co
Open published response
15 Feb 2019 Evie Alicia WRIGHT · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to provide the planned footbridge View source
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. 6
Action
Obtain Network Rail’s current bridge design requirements and convey them to the prospective planning applicant.
View source
Action
Meet Network Rail to seek bridge funding and agreement to interim improvements identified for the existing crossing.
View source
Action
Determine any planning application submitted for a new bridge within 13 weeks of submission.
View source
Action
Meet Persimmon Homes regarding its obligations to construct the bridge under the section 52 agreement.
View source
Action
Provide advice before submission of a new-bridge planning application to identify potential issues.
View source
Action
Seek agreement with Network Rail and Persimmon Homes on a draft project plan for delivering a new bridge.
View source See 3 more actions
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AI-generated summary
Evie Alicia WRIGHT · 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
Evie Alicia WRIGHT died immediately after walking onto a railway line near Corondale Crossing and being struck by a train on 6 March 2018. The report raised concerns about the long-delayed provision of a footbridge, which was described as enhancing safety and eliminating the risk associated with the crossing.
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× 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 North Somerset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the planned footbridge
Wider context from the report “However I also heard that in the vicinity of the crossing there was planning permission in place to build a footbridge . I have been told that such had been the position since 1991 ; that it was an obligation on the builder at the time to build a footbridge ; that planning permission had been granted in 2000 .
I heard a number of reasons and explanations why this has not happened .
I was told that there are now plans in relation to a new footbridge which is different in construction and that its location has moved hence it requires a fresh planning application and permission.
I have heard that a footbridge would enhance safety and eliminate risk , that network rail supports the closure of any crossing but has no power or responsibility – that rests with the North Somerset District Council and the developer – now Persimmon, who it should be noted were not the original developer.
” 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 Obtain Network Rail’s current bridge design requirements and convey them to the prospective planning applicant.
Verbatim wording from the response “• By 30th May we will seek Network Rail’s confirmation of the appropriate current design requirements for the bridge and convey those standards to Persimmon Homes (and/or whichever body it is agreed will submit a fresh planning application to current standards);” Source location 2019-0063-Response-by-North-Somerset-Council
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 Meet Network Rail to seek bridge funding and agreement to interim improvements identified for the existing crossing.
Verbatim wording from the response “• By 30th May we will meet with Network Rail to seek agreement to funding from Network Rail towards construction of a bridge and commitment in the meantime to make any identified improvements to the safety of the existing crossing;” Source location 2019-0063-Response-by-North-Somerset-Council
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 Determine any planning application submitted for a new bridge within 13 weeks of submission.
Verbatim wording from the response “• Within 13 weeks of its submission we will use our best endeavours to determine any planning application submitted to the Council for a new bridge and will provide advice prior to any application being submitted to identify any issues which may arise.” Source location 2019-0063-Response-by-North-Somerset-Council
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 Meet Persimmon Homes regarding its obligations to construct the bridge under the section 52 agreement.
Verbatim wording from the response “We will arrange to meet with Persimmon Homes to explore the issues in detail but I can confirm that I have already met with their regional Managing Director, ████████, Technical Director, ████████, on 26 March to discuss how to progress a response and as a matter of urgency.” Source location 2019-0063-Response-by-North-Somerset-Council
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 Provide advice before submission of a new-bridge planning application to identify potential issues.
Verbatim wording from the response “• Within 13 weeks of its submission we will use our best endeavours to determine any planning application submitted to the Council for a new bridge and will provide advice prior to any application being submitted to identify any issues which may arise.” Source location 2019-0063-Response-by-North-Somerset-Council
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 Seek agreement with Network Rail and Persimmon Homes on a draft project plan for delivering a new bridge.
Verbatim wording from the response “• By 30th July, we will seek agreement with Network Rail and Persimmon Homes to a draft project plan identifying the steps to be taken to deliver a new bridge.” Source location 2019-0063-Response-by-North-Somerset-Council
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 Network Rail is expected to resolve crossing safety issues, review risk assessments, contribute bridge funding and use compulsory purchase powers for required land.
Verbatim wording from the response “We are also firmly of the view that Network Rail has an essential role to play in resolving this issue and will seek its engagement in delivering a solution, and hope you agree. I note the importance attached by Network Rail on its website to closing such crossings and its statement that it has delivered closure of 1100 level crossings between 2009 and 2017. I trust that Network Rail will work positively with us on this particular crossing and am pleased that you have sent a copy of your report to Network Rail.” Source location 2019-0063-Response-by-North-Somerset-Council
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 Persimmon Homes is responsible for constructing the bridge under the section 52 agreement.
Verbatim wording from the response “• By 30th April we will meet with Persimmon Homes in connection with their obligations to construct the bridge under the section 52 agreement” Source location 2019-0063-Response-by-North-Somerset-Council
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 The Council lacks the authority or power to build the bridge itself.
Verbatim wording from the response “Recognising that the Council does not have the authority or power to build the bridge itself, we will therefore take the following actions:” Source location 2019-0063-Response-by-North-Somerset-Council
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 Building a bridge at the previously approved or an alternative location would not necessarily result in closure of the Corondale Crossing.
Verbatim wording from the response “Whilst I fully understand why much focus has been placed on the absence of a bridge, we feel it is important to emphasise that building the bridge in the previously approved location would not necessarily have led to the closure of the Corondale Crossing. As you will be aware, the bridge which received planning permission was some distance from the crossing. Building a bridge in an alternative location may also not necessarily lead to the closure of the crossing given the separate statutory process which must be followed. I therefore believe it is essential that Network Rail is requested to review the safety arrangements at the existing crossing and this is the first action we will take.” Source location 2019-0063-Response-by-North-Somerset-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations