9 Feb 2026 Helen Patching and 2 others · Prevention of Future Deaths report South Wales Central
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Concerns raised 4 Failure to provide information enabling walkers to understand official routes, path closures and risks View source Inadequate signage addressing the risk of accidental falling View source Poor or non-existent mobile telephone signal in remote areas View source High rate of trips and slips in Waterfall Country View source See 1 more concern
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
Helen Patching and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Helen Patching, Rachael Patching and Corey Longdon died accidental deaths in Waterfall Country within Bannau Brycheiniog National Park. The principal concerns were inadequate signage about the risk of accidental falling, walkers’ lack of understanding of routes and risks, and poor mobile telephone signal delaying alerts to emergency services.
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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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide information enabling walkers to understand official routes, path closures and risks
Wider context from the report “(2) A previous Prevention of Future Death report has led to the erection of signage concerning the risk of drowning in the water itself. However, the current signage provision does not adequately address the significant additional risk of accidental falling. Many walkers fail to understand the official routes, closed and open paths and the significant risks they face ;
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate signage addressing the risk of accidental falling
Wider context from the report “(2) A previous Prevention of Future Death report has led to the erection of signage concerning the risk of drowning in the water itself. However, the current signage provision does not adequately address the significant additional risk of accidental falling . Many walkers fail to understand the official routes, closed and open paths and the significant risks they face;
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Poor or non-existent mobile telephone signal in remote areas
Wider context from the report “(4) Mobile telephone signal is poor to non-existent in certain more remote areas , which creates delay in alerting emergency services when accidents do occur .
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation High rate of trips and slips in Waterfall Country
Wider context from the report “(1) There is a high rate of accidents, including some fatal accidents, from trips and slips in the area known as Waterfall Country ;
” 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 Contribute to implementing enhanced safety signage through the Waterfall Country safety working group.
Verbatim wording from the response “Powys County Council is represented on the Waterfall Country safety working group and is contributing to ongoing efforts, including the implementation of enhanced safety signage during the current year.” Source location Response from Powys County 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 Legally diverted paths and barriers are considered sufficient to deter access to hazardous routes where original paths were diverted.
Verbatim wording from the response “The public rights of way at the Waterfalls Country site at Ystradfellte are managed by the Bannau Brycheiniog National Park Authority under a formal delegation agreement. The paths have recently been legally diverted to align with managed routes, improving safe navigation for the public. Where original paths have been diverted, sufficient measures are in place to deter access to those routes where hazards exist, including the use of barriers.” Source location Response from Powys County Council
Open published response
13 Dec 2022 Akeem Jevaughn RHODEN · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Failure to provide adequate warning signage at points where individuals may decide to enter the water View source Failure of waterfall signage to provide clear, concise warnings about the power and dangers of the water 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
Akeem Jevaughn RHODEN · 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
Akeem Jevaughn Rhoden, aged 22, drowned after voluntarily jumping from a rock into the water at Sgwd y Pannwr Waterfall on 5 June 2021; he was not a strong swimmer and his body was recovered the following day. The concerns raised were that warning signs at waterfalls in Waterfall Country were inadequate, absent at the point where he entered the water, overloaded with information, and did not clearly explain the danger posed by the force of the water.
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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate warning signage at points where individuals may decide to enter the water
Wider context from the report “(1) The signage at ALL waterfalls in ‘Waterfall Country’ must be addressed;
(2) Akeem Roden was not a strong swimmer and there were no adequate signs at the point he jumped in to warn him of the potential dangers and that he might drown;
(3) Signage at each waterfall should be in plain, bold, easily understandable English, spelling out the danger of the power of the water;
(4) Existing signage is overloaded with information and not present at the point where individuals may decide to enter the water .
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of waterfall signage to provide clear, concise warnings about the power and dangers of the water
Wider context from the report “(1) The signage at ALL waterfalls in ‘Waterfall Country’ must be addressed;
(2) Akeem Roden was not a strong swimmer and there were no adequate signs at the point he jumped in to warn him of the potential dangers and that he might drown;
(3) Signage at each waterfall should be in plain, bold, easily understandable English, spelling out the danger of the power of the water ;
(4) Existing signage is overloaded with information and not present at the point where individuals may decide to enter the water.
” Open source report
26 Jul 2022 Hemanta Kumar Rai · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Unclear responsibility for the particular area View source Failure to provide adequate, clear signage warning of the risk of death by drowning 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
Hemanta Kumar Rai · 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
Hemanta Kumar Rai, aged 28, drowned in August 2021 after a strong current pulled him underwater towards a waterfall while he was visiting South Wales. The concerns were inadequate and unclear signage warning of the risk of death by drowning, and uncertainty about responsibility for the area.
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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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for the particular area
Wider context from the report “(4) It is very unclear who bears responsibility for this particular area, which borders 3 local authority areas, and falls within the National Park and NRW jurisdiction.
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate, clear signage warning of the risk of death by drowning
Wider context from the report “(1) There is no adequate signage to warn visitors of the risk of drowning by entering the water at Sgwd Gwladys.
(2) Existing signage in “Waterfall Country” is overloaded with a variety of information, which although helpful for walking routes etc, is not explicit in warning of the real danger of death from entering the water.
(3) Any sign(s) erected ought to be easily visible, in plain English and spell out the risk of death by drowning.
” Open source report
1 Jun 2022 Samuel Joseph Gomm · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments View source Failure of the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Samuel Joseph Gomm · 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
Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.
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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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments
Wider context from the report “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk.
(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.
(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.
(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded . Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments
Wider context from the report “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that , nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk .
(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user . This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.
(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.
(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm
” Open source report
14 Mar 2022 Mrs. Margaret May Lewis · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Risk of pedestrian collisions when crossing the B4398 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
Mrs. Margaret May Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Margaret May Lewis was fatally injured on 6 November 2020 when she was struck by a car while crossing the B4398 to re-join the Montgomeryshire Canal towpath. The report identifies concerns about the risk of similar accidents because the road has a 60 mph speed limit, electric cars may be difficult to hear, and pedestrians exercising may wear earphones.
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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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Risk of pedestrian collisions when crossing the B4398
Wider context from the report “The Montgomeryshire canal and its adjacent towpath is a popular venue for adults with children and dogs; and joggers many of whom will wear earphones. They, like Mrs. Lewis who was thought to be wearing earphones at the time, will need to cross the B4398 (which has a 60 mph speed limit) to continue their exercise.
With the increasing popularity of noiseless electric cars, the frequency of wearing earphones whilst taking exercise and the B4398 having a 60mph speed limit, I consider there is a risk of reoccurrence of such an accident.
Within the Highway Code for pedestrians it states “Keep looking and listening for traffic while you cross, in case there is any traffic you did not see, or in case other traffic appears suddenly. Do not walk diagonally across the road.”
” Open source report
19 Apr 2016 Rhodri Dafydd Miller-Binding and 3 others · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Lack of an advance warning sign for the approaching left bend 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
Rhodri Dafydd Miller-Binding and 3 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.
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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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an advance warning sign for the approaching left bend
Wider context from the report “1) The stretch of road along the A470 is subject to a 60 mile per hour speed limit
but is known to be particularly “challenging” stretch of road on which there have
been many serious injury and fatality collisions in the past. The evidence at the
inquest from the Forensic Collision Investigating Officer was clear in that an
advanced warning sign of an approaching left bend would be of significant
assistance in warning motorists of the nature of the road ahead and thereby
reducing the risk of a similar fatality.
Whilst there was evidence at the inquest to support the view that Rhodri Milling-
Binding’s vehicle was being driven at an inappropriate speed, it was not felt that any
form of speed restriction was appropriate at this location – simply an advanced warning
sign of the nature of the road ahead .
” Open source report
Concerns raised 3 Unusually high number of collisions at a particular road location View source Excessive vehicle speeds at or near the collision location View source Excessive vehicle speeds on bends at the road location 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
Brendan Owain Ryan · 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
Brendan Owain Ryan, aged 21, was the front-seat passenger in a Peugeot 205 that left the A488 between Pen-Y-Bont and Knighton on 31 July 2013 and collided with a fence before entering a field. He was declared deceased at the scene; the inquest concluded the death was due to a road traffic collision, with neck injuries recorded as the medical cause. The principal concern was an unusually high number of collisions at or near the location, with evidence indicating that excessive speed was likely, and consideration of a restricted speed area was raised.
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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Unusually high number of collisions at a particular road location
Wider context from the report “1. There is evidence of an unusually high number of incidents taking place at this particular location . Powys County Council are aware of three injury collisions and there is evidence, from the residents of Brook House, that there have been many accidents at or near this location which the evidence indicated are most likely to have been caused by excess speed. Furthermore it is believed there were three collisions at or near this collision site within a six day period surrounding this incident.
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Excessive vehicle speeds at or near the collision location
Wider context from the report “1. There is evidence of an unusually high number of incidents taking place at this particular location. Powys County Council are aware of three injury collisions and there is evidence, from the residents of Brook House, that there have been many accidents at or near this location which the evidence indicated are most likely to have been caused by excess speed . Furthermore it is believed there were three collisions at or near this collision site within a six day period surrounding this incident.
” 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 Powys County Council; that does not assign responsibility.
PFD Monitor interpretation Excessive vehicle speeds on bends at the road location
Wider context from the report “2. Evidence from the Collision Investigator in this case showed that the maximum speed at which the bends in this road at this location could be travelled at were 50 and 53 mph depending on the direction of approach . Whilst it is acknowledged that the County Council have installed new signage and double white lines in the area in light of the unusually high number of incidents in which vehicles appear to have left the road, most likely as a direct result of excessive speed , it is felt that consideration ought to be given to a restricted speed area at this location.
” 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 Erect additional series-of-bends warning signs on both approaches.
Verbatim wording from the response “Surveys into the signing and lining resulted in sections of double solid white centre line being introduced through the bends and additional series of bends warning signs being erected on both approaches. The solid centre lines were considered appropriate not just because of the reduced forward visibility but also from concerns raised by the Community Council of poor overtaking manoeuvres. Verge marker posts have also been added adjacent to the bridge parapet to highlight its presence and assist in denoting the road alignment.” Source location 2014-0541-Response-by-Powys-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 Introduce double solid white centre lines through the bends.
Verbatim wording from the response “Surveys into the signing and lining resulted in sections of double solid white centre line being introduced through the bends and additional series of bends warning signs being erected on both approaches. The solid centre lines were considered appropriate not just because of the reduced forward visibility but also from concerns raised by the Community Council of poor overtaking manoeuvres. Verge marker posts have also been added adjacent to the bridge parapet to highlight its presence and assist in denoting the road alignment.” Source location 2014-0541-Response-by-Powys-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 Implement temporary traffic management measures at the site pending completion of detailed surveys.
Verbatim wording from the response “Following the fatal collision on the 6th August 2013 a number of measures were taken at this site. This initially consisted of temporary traffic management measures until detailed surveys could be undertaken to establish the road conditions.” Source location 2014-0541-Response-by-Powys-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 Complete road-surface reprofiling works addressing the surveyed area of concern northwest of the bridge.
Verbatim wording from the response “The surface grip test indicated that the surface was fine but a topographical survey noted a small area of concern to the northwest of the bridge. As a result of the survey, a reprofiling scheme was identified and works were completed during summer of 2014 following a successful bid to the Welsh Government for grant funding.” Source location 2014-0541-Response-by-Powys-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 Add verge marker posts beside the bridge parapet to highlight the bridge and road alignment.
Verbatim wording from the response “Surveys into the signing and lining resulted in sections of double solid white centre line being introduced through the bends and additional series of bends warning signs being erected on both approaches. The solid centre lines were considered appropriate not just because of the reduced forward visibility but also from concerns raised by the Community Council of poor overtaking manoeuvres. Verge marker posts have also been added adjacent to the bridge parapet to highlight its presence and assist in denoting the road alignment.” Source location 2014-0541-Response-by-Powys-County-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 Existing engineering measures are considered sufficient to meet the authority’s duty, and guidance makes a lower speed limit inappropriate for this individual hazard.
Verbatim wording from the response “These engineering measures are considered appropriate measures to meet the duty of this Authority under Section 122 of the Road Traffic Regulation Act 1984 as amended. Given this and the Welsh Government guidance not recommending speed limits for individual hazards it is not considered appropriate to impose a lower speed limit at this location.” Source location 2014-0541-Response-by-Powys-County-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations