6 Dec 2024 Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report North London
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Concerns raised 8 Inadequate information management for analysis and learning from white goods fires View source Failure by fire-investigating companies to notify authorities of investigation outcomes View source Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters View source Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire View source Failure of product risk assessments to account for occupants and their actions View source Lack of sharing of warranty replacement data for condensate pumps and RFI filters View source Failure to provide fire-durable identification plates on appliances View source Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Champagauri Bhatt and Dipak Bhatt · 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 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.
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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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate information management for analysis and learning from white goods fires
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires .
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure by fire-investigating companies to notify authorities of investigation outcomes
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations .
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire .
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure of product risk assessments to account for occupants and their actions
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates .
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of warranty replacement data for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters .
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fire-durable identification plates on appliances
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards .
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Arrange testing against the Standard of a test purchase of the affected tumble-dryer model.
Verbatim wording from the response “There is a model of the tumble dryer containing the condensate pump referred to in your report which is no longer manufactured but is still available on the market. I have asked the trading standards service to arrange for testing against the Standard of a test purchase of the model as an additional check on the company’s findings.” Source location Response from North Yorkshire Council
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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 A recall and component improvements are considered unnecessary based on the absence of other complaints and satisfactory test outcomes.
Verbatim wording from the response “Neither this service nor Hotpoint UK Appliances Ltd has received any other complaint about the identified parts overheating or causing a fire. Since the receipt of the Prevention of Future Deaths report, the company has conducted forced failure testing going beyond that required by the Standard. The testing was conducted at an in-house facility in Italy so could not be observed by a trading standards officer, however, it was overseen by ████████ of the Beko Europe Safety team. ████████ is a member of the IEC TC89 Committee reviewing safety standards for Fire Hazard, and it has been confirmed that she was fully aware of the Bhatt case and the verdict. The filters and pumps passed all the tests.” Source location Response from North Yorkshire Council
Open published response
Concerns raised 2 Lack of residential substance misuse treatment facilities for under-18s View source Failure to search beyond the county boundary for suitable accommodation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin NELSON-ROUX · 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
Benjamin Nelson Roux, aged 16, was found deceased on 8 April 2020 after taking multiple drugs of abuse; the cause of death was unascertained. Concerns included the lack of suitable accommodation options beyond the county boundary for a homeless 16-year-old Child in Need and the lack of residential substance-misuse treatment facilities for people under 18.
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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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of residential substance misuse treatment facilities for under-18s
Wider context from the report “2. The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18 .
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to search beyond the county boundary for suitable accommodation
Wider context from the report “1. The search for suitable accommodation (in this instance for a homeless 16 year old Child in Need) did not extend beyond the County boundary .
” 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 Explore relationships with neighbouring housing authorities بشأن suitable accommodation for under-18s, potentially including signposting to registered social landlords.
Verbatim wording from the response “The Council will explore the possibilities of establishing relationships with neighbouring local housing authorities regarding potential suitable housing accommodation for persons under 18. This would possibly signpost to registered social landlords.” Source location Response from North Yorkshire 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 Amend the accommodation pathway to assess the possibility and suitability of out-of-area placements when local accommodation is unavailable.
Verbatim wording from the response “The accommodation pathway will be amended to review the possibility and suitability of any out of area placement, in the cases of a young person where accommodation is not available within the local authority area.” Source location Response from North Yorkshire Council
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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 Residential substance-misuse treatment provision for under-18s will be addressed by the Coroner directly with the Secretary of State.
Verbatim wording from the response “2. The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18.” Source location Response from North Yorkshire Council
Open published response
Concerns raised 2 Failure of roadway drainage and engineering to safely clear and channel storm and rainwater View source Lack of signage warning road users of flooding and loss-of-control risk 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.
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AI-generated summary
Sasha Raven Marie Brown · 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
Sasha Raven Marie Brown was the unaccompanied driver of a car that lost control on a very wet section of the A6068 and collided with an oncoming vehicle on 19 January 2021. The principal concerns were inadequate drainage and road design, the absence of flood-risk signage, and the reported ongoing high risk to motorists from surface water at that location.
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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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure of roadway drainage and engineering to safely clear and channel storm and rainwater
Wider context from the report “It is acknowledged that officers of the Highway Authority were not called to give evidence at the Inquest Hearing nor was the Authority designated as an Interested Person for the purposes of disclosure and participation at the Hearing. There had been a written Report Collision ref 01-21 however from the Authority received at the Hearing relating to the roadway being the “A6068 Colne Road between Carr Head Lane and New Hall Farm near Cowling/Crosshills, Craven District”
However the evidence revealed:
a) The particular stretch of the A6068 was known to local, and other motorists familiar with it, as being frequently incapable of adequately and safely clearing surface storm and rainwater off the carriageway surface , thereby to make the road as reasonably safe as possible for the passage of motor vehicles, especially those travelling down the incline (as was the deceased).
b) That water flowed and flows rapidly down the incline. It was (and is) not adequately regulated by drains and did not (and does not) get away . Instead water which came off (and comes off) adjacent land as well as the road itself accumulated (and accumulates) in volume. The want of appropriate cambers and slopes across the carriageway allowed (and allows) and indeed encouraged (and encourages) the water flow across the whole of the carriageway, rather than be conducted along drainage channels to the sides of the carriageway .
c) The profile of the roadway meant (and means) that the water was (and is likely to be) thrown back (and forth) across the carriageway. The evidence showed a heavy water flow spread right across the carriageway into the deceased’s path from the deceased’s offside to nearside. That had been from an accumulation of water after there was a flow nearside to offside a short distance back from the incident scene.
d) The process of simply cleaning out drains was not (and has not been) adequate to minimise the risk to road users . The evidence pointed to the need to make significant permanent road engineering alterations to the camber, layout, profile and slopes of the road surface and drains . The evidence indicated that the high levels of traversing water were not rare occurrences, creating what was found to be a ‘notoriety’. Climate change will increase the likelihood of adverse incidents such as was evidenced happening in the future, causing increased risk of death. The roadway here will remain a high risk, as it was for the deceased, for fatal accidents.
e) There were (and are) no signs/signage indicating the risk of the road ‘flooding’, whether temporary or permanent at this location. Those familiar with it, including the Police expert, knew it for the past and present risk of loss of control. That should not mean the risk can be acceptable.
f) The Authority must consider promptly permanent road engineering solutions and implement those appropriate to make this road as safe as reasonably possible.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage warning road users of flooding and loss-of-control risk
Wider context from the report “It is acknowledged that officers of the Highway Authority were not called to give evidence at the Inquest Hearing nor was the Authority designated as an Interested Person for the purposes of disclosure and participation at the Hearing. There had been a written Report Collision ref 01-21 however from the Authority received at the Hearing relating to the roadway being the “A6068 Colne Road between Carr Head Lane and New Hall Farm near Cowling/Crosshills, Craven District”
However the evidence revealed:
a) The particular stretch of the A6068 was known to local, and other motorists familiar with it, as being frequently incapable of adequately and safely clearing surface storm and rainwater off the carriageway surface, thereby to make the road as reasonably safe as possible for the passage of motor vehicles, especially those travelling down the incline (as was the deceased).
b) That water flowed and flows rapidly down the incline. It was (and is) not adequately regulated by drains and did not (and does not) get away. Instead water which came off (and comes off) adjacent land as well as the road itself accumulated (and accumulates) in volume. The want of appropriate cambers and slopes across the carriageway allowed (and allows) and indeed encouraged (and encourages) the water flow across the whole of the carriageway, rather than be conducted along drainage channels to the sides of the carriageway.
c) The profile of the roadway meant (and means) that the water was (and is likely to be) thrown back (and forth) across the carriageway. The evidence showed a heavy water flow spread right across the carriageway into the deceased’s path from the deceased’s offside to nearside. That had been from an accumulation of water after there was a flow nearside to offside a short distance back from the incident scene.
d) The process of simply cleaning out drains was not (and has not been) adequate to minimise the risk to road users. The evidence pointed to the need to make significant permanent road engineering alterations to the camber, layout, profile and slopes of the road surface and drains. The evidence indicated that the high levels of traversing water were not rare occurrences, creating what was found to be a ‘notoriety’. Climate change will increase the likelihood of adverse incidents such as was evidenced happening in the future, causing increased risk of death. The roadway here will remain a high risk, as it was for the deceased, for fatal accidents.
e) There were (and are) no signs/signage indicating the risk of the road ‘flooding’, whether temporary or permanent at this location . Those familiar with it, including the Police expert, knew it for the past and present risk of loss of control . That should not mean the risk can be acceptable.
f) The Authority must consider promptly permanent road engineering solutions and implement those appropriate to make this road as safe as reasonably possible.
” Open source report
Concerns raised 2 Lack of instructions on the circumstances for using specific prescribed equipment View source Lack of monitoring of compliance with equipment-use instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dorothy Pegg · 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
Dorothy Pegg slipped from a shower chair while sitting on a sling and suffered bilateral leg fractures, which contributed to her death. The report identified concerns about the absence of monitoring for compliance with equipment-use instructions and the lack of instructions about when specific prescribed equipment should be used.
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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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions on the circumstances for using specific prescribed equipment
Wider context from the report “2. There were no instructions as to the circumstances in which it is appropriate that specific prescribed equipment is used.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of compliance with equipment-use instructions
Wider context from the report “1. There was no system of monitoring the compliance with instructions as to how equipment should be used.
” 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 Revise moving-and-handling assessment templates to identify the assessed equipment task and require advice before use outside that scope.
Verbatim wording from the response “➢ NYCC will change moving and handling risk assessment and plan templates to have a descriptor box at the top to clearly identify the task for which the equipment has been assessed and provided for by the OT. There will also be a point of note that if the equipment is to be used outside this scope, advice should be sought by the care provider from an appropriately trained person. The updated template will be uploaded to NYCC’s case recording system (LLA) and is to be used as from 31 January 2022.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Request that ICES make equipment instruction leaflets retrievable from its database for occupational therapists.
Verbatim wording from the response “➢ In addition to the above, on 25 November 2021, NYCC has requested ICES to provide instruction leaflets for equipment on the equipment database for retrieval by Occupational Therapists to accompany moving and handling risk assessment and plans. This request has been followed up via email with ICES who have confirmed that work will start on this week commencing 20th December 2021.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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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 Notify equipment prescribers through the ICES newsletter about the new moving-and-handling templates.
Verbatim wording from the response “➢ There are a range of roles across the NHS and Local Authority that can prescribe equipment including physiotherapists and OT’s. The Integrated Community Equipment Service (ICES) is a jointly funded service between the NHS and Local Authority and will alert prescribers of equipment to the new moving and handling document through a newsletter. A notification is sent to each user of the ICES to make them aware of the newsletter which includes equipment updates and alerts. The next newsletter is scheduled for early 2022 and will contain an article to introduce the new templates. A prompt is included in the Equipment Request Form on the ICES database as a reminder to non-NYCC prescribers to complete a moving and handling risk assessment and plan. A quarterly dip sample audit of the Equipment Request Form will be completed to monitor compliance with the new arrangement.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Reinforce with ICES the contractual requirement to supply equipment with instruction leaflets.
Verbatim wording from the response “➢ NYCC have reminded ICES of the contractual requirement to deliver all equipment accompanied by an instruction leaflet. This requirement was included as an agenda item in The Vale of York’s (as lead commissioner) Performance and Quality meeting on 25 November 2021 attended by NHS and Local Authority commissioners and representatives from ICES. Following the meeting the contractual requirement was reiterated via an email from OT Lead for the Local Authority to ICES.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Introduce dedicated occupational-therapy training on completing moving-and-handling assessments and plans, incorporating learning from the inquest.
Verbatim wording from the response “➢ Future training for new or existing OTs is to include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans. The learning from” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Require care-provider contracts to specify that prescribed equipment is used for its assessed purpose and that changes are reflected in care plans.
Verbatim wording from the response “➢ NYCC will ensure that contracts with care providers have reference within the terms and conditions that any equipment prescribed is used for the assessed purpose. NYCC will also ensure that any change to provision or use is to be incorporated and updated by providers within their care plans. These actions will be achieved by 31 March 2022.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Deliver specialist moving-and-handling training for NYCC occupational therapists focused on equipment purpose and moving-and-handling plans.
Verbatim wording from the response “➢ A specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Use a practice review meeting to reinforce clarity about the intended task when moving-and-handling plans are completed and shared.
Verbatim wording from the response “➢ An agenda item was included in a NYCC Practice Review meeting on 29th November 2021 and attended by OT Team Managers, Senior OTs and Training & Learning representatives to ensure that when moving and transferring plans are completed and shared with the person and/or their carers, these include clarity on the task for which equipment is intended. When the revised moving and handling risk assessment and plan templates are uploaded onto NYCC’s case recording system, a reminder will be sent to all OTs to use the new template forms.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Share and reinforce correct equipment, moving-and-handling-plan, and care-plan practices through care-provider forums, bulletins, and online events.
Verbatim wording from the response “➢ NYCC will utilise its care provider forums to share and reinforce correct practice (for example, around moving and handling plans always accompanying relevant equipment provision) and to share practice around care plans being updated at any equipment change. We propose to share such information via NYCC’s provider forums, provider bulletins and Care Connected (a regular online provider event). These actions will be achieved by 31 March 2022.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Use the revised templates in NYCC’s case-recording system and remind occupational therapists to adopt them.
Verbatim wording from the response “➢ NYCC will change moving and handling risk assessment and plan templates to have a descriptor box at the top to clearly identify the task for which the equipment has been assessed and provided for by the OT. There will also be a point of note that if the equipment is to be used outside this scope, advice should be sought by the care provider from an appropriately trained person. The updated template will be uploaded to NYCC’s case recording system (LLA) and is to be used as from 31 January 2022.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
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 Monitoring compliance with equipment-use instructions is assigned to Abbeyfields the Dales rather than North Yorkshire County Council.
Verbatim wording from the response “1. There was no system of monitoring the compliance with instructions as to how equipment should be used.” Source location 2021-0358-Response-from-North-Yorkshire-County-Council_Published
Open published response
Concerns raised 3 Lack of safety warnings about unseen cold-water and water-flow hazards View source Unavailability of water-rescue aids at incident scenes View source Lack of ready access to places of safety and support for casualties 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.
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AI-generated summary
MOHAMMED BILAL ZEB · 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
MOHAMMED BILAL ZEB, aged 18, drowned after jumping into the River Wharfe at Linton Falls on 31 July 2020; he could not swim and became unresponsive. Concerns included the absence of flotation or rescue aids, difficult access and conditions for rescuers, and a lack of apparent safety warnings about hazards including cold water, water flow and underwater obstructions.
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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safety warnings about unseen cold-water and water-flow hazards
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident.
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties.
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards . Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels .
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of water-rescue aids at incident scenes
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident .
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties.
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to places of safety and support for casualties
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident.
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties .
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels.
” Open source report
Concerns raised 1 Lack of street lighting in the collision area and at nearby bus stops View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Luke John Saxton · 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
Luke John Saxton was struck by a motor car while walking along the A59 in darkness on 23 June 2018 and died at the scene from his injuries. The principal concern was that the collision location and nearby bus stops had no street lighting, despite the area being near a popular wedding venue.
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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of street lighting in the collision area and at nearby bus stops
Wider context from the report “1) The collision occurred in darkness in an area where there was no street lighting ;
2) Mr Saxton had been attending a wedding at nearby Broughton Hall, a popular wedding venue;
3) There are bus stops in the area where the collision occurred which were also in darkness ;
4) Consideration should be given to erecting street lighting to cover the area where the collision occurred up to the bus stops at either side of the Bull at Broughton public house.
” Open source report
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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 Street lighting is not considered necessary because collision history, pedestrian and night-time traffic flows, precedent, and costs do not justify intervention.
Verbatim wording from the response “When assessing the need for street lighting a range of factors are considered, one of the most significant being the long term collision record.” Source location 2018-0373-Response-by-North-Yorkshire-County-Council
Open published response
Concerns raised 5 Restricted visibility of traffic at the junction View source Incorrect junction warning signage View source Obstructed visibility of traffic from a roadside wall View source Visibility of national speed limit signs before the junction View source Limited signage for the junction with the lane to Knowles cottages View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Wallace · 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 23 April 2016, Thomas Wallace died at the scene after his motorcycle collided with a car that had pulled out from a lane onto the A682 at Long Preston. Concerns included the restricted visibility at the junction, the wall alongside the road, limited and potentially misleading signage, and the positioning of national speed limit signs.
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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Restricted visibility of traffic at the junction
Wider context from the report “(1) The layout of the junction affords an extremely restricted view of traffic on the A682.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Incorrect junction warning signage
Wider context from the report “(4) There is a staggered junction sign where there appears to be a cross roads.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Obstructed visibility of traffic from a roadside wall
Wider context from the report “(2) The solid wall running alongside the A682, contributes to the restricted view of the traffic on the A682.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Visibility of national speed limit signs before the junction
Wider context from the report “(5) The national speed limit signs placed immediately after the junction are visible in advance of being able to see the junction.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Limited signage for the junction with the lane to Knowles cottages
Wider context from the report “(3) The signage on the A682 regarding the junction with the lane down to Knowles cottages is very limited.
” Open source report
Concerns raised 9 Failure to record the basis for land-ownership conclusions View source Failure to make written time-bound ownership enquiries View source Failure to prevent prolonged drift of an unresolved flooding issue View source Failure by inspectors to report potential hazards View source Failure by inspectors to report actions taken to address hazards View source Failure to record reports of flooding View source Failure to act on reported flooding View source Failure to establish the relevant land occupier View source Failure to progress resolution of the flooding issue View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William David McCourt · 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
William David McCourt died at the scene after losing control of his motorcycle on running water across the A6108 road. The warning sign had fallen over, and the water hazard had reportedly remained unresolved for several months. Concerns included missing records of residents’ reports, inadequate investigation of land ownership, lack of written escalation, failure to address the hazard, and inspections not recording the water as a potential hazard.
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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record the basis for land-ownership conclusions
Wider context from the report “2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion , neither did the maintenance manager visit the occupier of the land from which the water was flowing.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make written time-bound ownership enquiries
Wider context from the report “4) Nothing was ever put in writing to the Ministry of Defence requiring them to notify the Highways Authority within a reasonable time scale as to whether they owned the land and if so what action would be taken and by when.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent prolonged drift of an unresolved flooding issue
Wider context from the report “5) This situation was allowed to ‘drift’ over at least a 3 month period prior to the accident .
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure by inspectors to report potential hazards
Wider context from the report “6) Inspectors should have reported all potential hazards and actions taken to address 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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure by inspectors to report actions taken to address hazards
Wider context from the report “6) Inspectors should have reported all potential hazards and actions taken to address 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 North Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record reports of flooding
Wider context from the report “1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken.
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act on reported flooding
Wider context from the report “1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken .
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the relevant land occupier
Wider context from the report “2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing .
” 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 Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to progress resolution of the flooding issue
Wider context from the report “3) Over a three month period nothing was done to address the issue other than to telephone the Ministry of Defence . The Ministry of Defence did not provide an answer to the question of ownership of the land until after this accident when they confirmed that they were not responsible for the land in question.
” 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 Provide staff training to minimise human errors in logging and recording enquiries.
Verbatim wording from the response “(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.” Source location 2013-0383-Response-by-North-Yorkshire-County-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 Give staff clearer direction to ensure more detailed records are created in future.
Verbatim wording from the response “(2) It was acknowledged at the inquest that on this occasion more detailed notes should have been taken and clearer direction is now being given to staff to ensure better records exist in the future. The Maintenance Manager, in this instance, was given every indication by the representative of the Ministry of Defence that they were responsible for the land in question and hence no further enquiries were made. It appeared that the farm buildings were unoccupied at the time the flooding event occurred.” Source location 2013-0383-Response-by-North-Yorkshire-County-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 Circulate advice to relevant highway officers requiring actionable defects and warning signs to remain recorded until resolved.
Verbatim wording from the response “(6) North Yorkshire County Council’s highway officers record actionable defects (i.e those defects where work is intended) when carrying out inspections of the highway network. If temporary warning signs are in place to alleviate a hazard, the defect/warning signs should still be recorded until it has been resolved. Further advice has now been circulated to relevant highways officers through their managers to assert that this process is followed in future.” Source location 2013-0383-Response-by-North-Yorkshire-County-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 Review customer-contact recording systems to support robust logging and recording.
Verbatim wording from the response “(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.” Source location 2013-0383-Response-by-North-Yorkshire-County-Council
Open published response
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Request correction
Addressed to North Yorkshire County Council, now represented here by North Yorkshire Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations