Concerns raised 3 Lack of evidence that other breakwater deterrence measures are effective View source Dangerous jumping from and water around the breakwater View source Lack of lifeguard cover at the breakwater during higher-risk spring and summer periods 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
DAVID CHIAKA EJIMOFOR · 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
DAVID CHIAKA EJIMOFOR, aged 15, drowned after jumping into the sea from a breakwater at Aberavon on 19 June 2023. The principal concerns were the absence of lifeguards during higher-risk periods, despite their historical use to deter jumping, and the lack of evidence that alternative deterrence measures were effective.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence that other breakwater deterrence measures are effective
Wider context from the report “(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it.
(2) Jumping from, and the water around, the breakwater is known to be dangerous.
(3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk.
(4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today.
(5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Dangerous jumping from and water around the breakwater
Wider context from the report “(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it.
(2) Jumping from, and the water around, the breakwater is known to be dangerous.
(3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk.
(4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today.
(5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of lifeguard cover at the breakwater during higher-risk spring and summer periods
Wider context from the report “(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high) , when children and young people have been seen/known to jump into the water from it.
(2) Jumping from, and the water around, the breakwater is known to be dangerous.
(3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk.
(4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today.
(5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk.
” Open source report
×
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 Prepare a post-season report containing recommendations based on the monitoring findings.
Verbatim wording from the response “The purpose of the daily monitoring is to understand how many people are using Little Beach and, importantly, how many people are entering the water from the breakwater. This will allow the RNLI to make recommendations to its partner, Neath Port Talbot Council.” Source location Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Open published response
×
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 Monitor daily use of Aberavon beach, Little Beach and the breakwater throughout the 2025 lifeguarding season.
Verbatim wording from the response “1. Undertaking daily monitoring of people using:” Source location Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Open published response
×
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 Preventing access to water should be undertaken by security guards or wardens rather than lifeguards deployed to facilitate bathing.
Verbatim wording from the response “Lifeguards are normally deployed to facilitate bathing rather than preventing aquatic activities. If solely deployed to stop access it would be more appropriate to deploy a security guard or warden service.” Source location Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Open published response
×
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 Lifeguarding cannot be provided without the landowner’s request or consent, and the RNLI has no contract with the breakwater owner.
Verbatim wording from the response “As set out at the inquest, although the RNLI chooses to provide lifeguarding services, it has no legal duty to do so. Importantly, it cannot provide any service without the landowners or the occupier’s request or consent. It is entirely a matter for the landowner or occupier whether they ask and contract with the RNLI to provide a lifeguarding service.” Source location Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Open published response
×
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 Universal signage and access restrictions are impracticable; fencing is cost-prohibitive and may be circumvented by people entering the water around it.
Verbatim wording from the response “Restricting access or even universal provision of signage at all possible sites would be almost impossible and, in many locations, would prove to be highly unpopular.” Source location Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the ResilienceDirect page with RNLI capability information for emergency services and search-and-rescue partners.
Verbatim wording from the response “7. It is clear from the inquest that more work needs to be undertaken so that other emergency services/search and rescue partners understand the RNLI’s capabilities and how it operates.” Source location Response from Royal National Lifeboat Institution
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 Prepare materials for direct sharing with emergency-services partners covering RNLI capabilities and limitations, including search equipment and communication capabilities.
Verbatim wording from the response “8. Further it is also clear that more work needs to be undertaken to ensure emergency services/search and rescue partners understand the terminology that is used in relation to the RNLI to avoid any confusion or misunderstanding with those emergency services/search and rescue partners. By way of example around the difference between tasking and launching.” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Lifeboat communications should remain routed through Coastguard tasking; direct contact by other agencies is inappropriate because conflicting messages could distract crews.
Verbatim wording from the response “5. As the Coastguard is the tasking authority and responsible for coordinating searches, the method of communication with the Lifeboat is via the Coastguard following IMSAR protocols as a maritime search and rescue capability. Having other multiple organisations able to communicate with the Lifeboat is not effective. It can lead to conflicting information being given and undermine effective tasking as well as creating a distraction for the crews receiving multiple messages. This, in turn, could hamper the effectiveness of the lifesaving service and lives could be lost if the crew are distracted or given conflicting information.” Source location Response from Royal National Lifeboat Institution
Open published response
Concerns raised 3 Failure to mitigate shortfalls in lifeguard service with additional emergency service resource View source Lack of a published public plan for managing reduced lifeguard service View source Lack of adequate coastguard cover around the Cornish coastline View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Deliver local, regional and national beach-safety communications through media, social media, websites, radio, television, leaflets and stakeholder distribution.
Stated completedThe respondent said that this action was complete when they made their response on 19 October 2020. View source
Action
Provide roving and observational patrols, casualty care, and community access to RNLI rescue equipment at unguarded beaches.
Stated completedThe respondent said that this action was complete when they made their response on 19 October 2020. View source
Action
Roll out RNLI lifeguarding cover to 177 beaches during the 2020 season, including 47 beaches in Cornwall.
Stated completedThe respondent said that this action was complete when they made their response on 19 October 2020. View source
×
AI-generated summary
Anthony John WILLIAMSON · 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
Anthony John Williamson, an experienced kayaker, departed from Trebarwith Strand in a group and was later recovered from the sea after coming out of his kayak in heavy swells at Cambeath Point. He could not be resuscitated, and a final post-mortem cause of death was awaited. Concerns were raised about the adequacy of coastguard cover during the Coronavirus pandemic and whether reduced lifeguard services were being mitigated by additional emergency-service resources.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to mitigate shortfalls in lifeguard service with additional emergency service resource
Wider context from the report “It is not clear to me whether there were lifeguards on duty at Trebarwith Strand or elsewhere in north Cornwall at the time of this incident. My further, current cause for concern is that, where there may be a reduced lifeguard service , how any shortfall may be mitigated by additional coastguard or other emergency service resource . Is there a published plan giving notice to the public on how the situation is being managed?
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of a published public plan for managing reduced lifeguard service
Wider context from the report “It is not clear to me whether there were lifeguards on duty at Trebarwith Strand or elsewhere in north Cornwall at the time of this incident. My further, current cause for concern is that, where there may be a reduced lifeguard service, how any shortfall may be mitigated by additional coastguard or other emergency service resource. Is there a published plan giving notice to the public on how the situation is being managed?
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate coastguard cover around the Cornish coastline
Wider context from the report “My current cause for concern is to ensure that there is an adequate level of coastguard cover around the Cornish coastline . To what extent, if at all, has the Coronavirus pandemic caused a reduction in the level of coastguard protection in comparison to 2019? If there has been a reduction in the level of cover, how has this been mitigated? Is the amount of cover now at an acceptable level?
” Open source report
×
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 local, regional and national beach-safety communications through media, social media, websites, radio, television, leaflets and stakeholder distribution.
Verbatim wording from the response “• Local social media and PR campaigns” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
×
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 roving and observational patrols, casualty care, and community access to RNLI rescue equipment at unguarded beaches.
Verbatim wording from the response “The RNLI undertook a significant number of preventive measures including:” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
×
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 Roll out RNLI lifeguarding cover to 177 beaches during the 2020 season, including 47 beaches in Cornwall.
Verbatim wording from the response “At a Gold meeting on 27 May 2020, it was proposed to look at extending the service beyond 70 beaches. This proposal was subsequently approved by Trustees on the basis that the initial 70 beach model was now proven. Plans were put in place to rollout to an additional 100 beaches by early July, providing cover on c. 170 beaches for the peak season. Work was then undertaken to identify the additional beaches and ensure they could be lifeguarded safely. The rollout of those beaches took place in the period June to August alongside the ongoing rollout to the initial 70 beaches.” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
×
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 An immediate full lifeguarding service could not be delivered because achievable cover depended on advance notice of relaxed public restrictions.
Verbatim wording from the response “At the same time as planning the service within the constrictions set out above, the Chief Executive wrote to the Prime Minister and the Department of Transport explaining that it would be impossible to deliver an immediate full service: the level of lifeguarding service which it” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
×
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 There is no legal duty to provide lifeguarding, and service provision requires landowner or occupier request or consent.
Verbatim wording from the response “The report is clear that although the RNLI chooses to provide a lifeguarding service, it has no legal duty to do so. Importantly, it cannot provide any service unless the landowner/occupier requests or consents to it. It is entirely a matter for the landowner/occupier whether they ask and contract with the RNLI to provide a lifeguarding service, should they determine to provide a service as a risk control measure.” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
×
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 Responsibility for the public’s use of beaches and related safety decisions rests with the landowner or occupier.
Verbatim wording from the response “In April 2020, the RNLI started work on what steps could be taken to try and mitigate the absence of lifeguards on beaches. However, as set out above, any legal responsibility for the public’s use of beaches is a matter for the landowner/occupier.” Source location 2020-0153-Response-from-the-RNLI.pdf
Open published response
Concerns raised 3 Lack of publicly available information on beach lifeguard cover View source Lack of a published plan for mitigating lifeguard-cover shortfalls View source Reduced or absent lifeguard cover on Cornish beaches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jan KLEMPAR · 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
Jan Klempar was swimming in the sea at Porthcurno in west Cornwall, where no lifeguards were on duty despite the beach ordinarily having lifeguard cover. The concerns raised relate to reduced or absent lifeguard cover on Cornish beaches, public information about coverage, and plans to mitigate shortfalls through additional emergency resources.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly available information on beach lifeguard cover
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach .
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of a published plan for mitigating lifeguard-cover shortfalls
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach.
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Reduced or absent lifeguard cover on Cornish beaches
Wider context from the report “1) I have previously written drawing to your attention my concerns about a reduced level of lifeguard cover on Cornish beaches (Pender deceased.) I understand that from a position of no lifeguard cover (Whitsun Bank Holiday) there is now some service at a number of the main beaches. It is not clear to me whether the level of service will be further increased to 2019 levels or whether there will be a reduced service for the rest of the summer season ? Is there a published plan available to the public that sets out where lifeguard cover will be provided and specifies the beaches, if any, that will either have a reduced service or no service this year in comparison to 2019 ? Given the difficulties with international travel currently, and the consequent likelihood of high numbers of tourists in Cornwall, it seems to me this information needs to be made readily available so the public can inform themselves of the risks of bathing at a given beach.
2) Where there may be a reduced or no lifeguard cover at particular beaches, is there a published plan specifying how any shortfalls may be mitigated through the provision of additional resource from the coastguard or other emergency provider?
” Open source report
×
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 Disseminate beach-cover information and safety messages through websites, social media, press, broadcast media, campaigns and stakeholder leaflets.
Verbatim wording from the response “In our letter dated 24 July 2020, we set out that there have been numerous announcements setting out which beaches would be patrolled and by what date. The RNLI’s local media team in Cornwall worked very closely with Cornwall County Council’s media department and announcements/press releases frequently appeared on Cornwall County Council’s website giving updates as beaches were added. For example:” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
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 Develop and implement a risk-based 2020 lifeguarding rollout, providing cover on 177 beaches, including 47 beaches in Cornwall.
Verbatim wording from the response “During April, the options were fully worked-up and considered by Gold team, the Executive Team and the Trustees. It was agreed that lifeguarding would be provided on approximately 48 beaches. The beaches that would be lifeguarded would be based on risk and professional judgement, ensuring a geographic spread across the UK and Channel Islands so that the UK beach going public would be able to visit an RNLI lifeguarded beach once restrictions permitted. Of those 48 beaches, approximately 25 are ‘Easter’ beaches and primarily southwest based. At the beginning of May, the plan was increased to cover 70 beaches having discussed the intention to provide cover across 70 beaches with the Maritime and Coastguard Agency.” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
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 roving and observational patrols, casualty care and access to rescue equipment at beaches without normal lifeguard cover.
Verbatim wording from the response “The RNLI undertook a significant number of preventive measures including:” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RNLI cannot provide lifeguarding unless the landowner or occupier requests or consents to the service.
Verbatim wording from the response “The report is clear that although the RNLI chooses to provide a lifeguarding service, it has no legal duty to do so. Importantly, it cannot provide any service unless the landowner/occupier requests or consents to it. It is entirely a matter for the landowner/occupier whether they ask and contract with the RNLI to provide a lifeguarding service, should they determine to provide a service as a risk control measure.” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
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 Responsibility for beach users’ safety rests with the landowner or occupier, rather than the RNLI.
Verbatim wording from the response “The report is clear that although the RNLI chooses to provide a lifeguarding service, it has no legal duty to do so. Importantly, it cannot provide any service unless the landowner/occupier requests or consents to it. It is entirely a matter for the landowner/occupier whether they ask and contract with the RNLI to provide a lifeguarding service, should they determine to provide a service as a risk control measure.” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
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 An immediate full lifeguarding service was impossible because its level depended on advance notice of relaxed public restrictions.
Verbatim wording from the response “At the same time as planning the service within the constrictions set out above, the Chief Executive wrote to the Prime Minister and the Department of Transport explaining that it would be impossible to deliver an immediate full service: the level of lifeguarding service which it could provide would depend on the amount of notice the RNLI was given of the relaxing of public restrictions.” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
×
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 announcements, websites, social media and safety campaigns were considered sufficient to inform the public about limited lifeguard coverage and beach risks.
Verbatim wording from the response “The RNLI believes that it and its partners including the County Council, HM Coastguard and the Police put out a significant and widespread number of press releases and/or details on websites, informing the public that there was limited lifeguard cover, confirming which beaches had cover, the dates of that cover and providing a link to the RNLI website which set out all this information.” Source location 2020-0152-Response-from-RNLI.pdf
Open published response
Concerns raised 2 Lack of publicly available information on planned lifeguard patrol locations and timing View source Unavailability of professional lifeguard cover on Cornwall beaches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Louisa Davey died after a pleasure craft capsized off the north Cornish coast, trapping her underneath, and Michael Pender died after being rescued from the sea off Treyarnon Bay, apparently having been caught in a rip current. The principal concern was that there was no lifeguard cover on any Cornish beach that day, with uncertainty about when professional lifeguard services would resume and concern about further loss of life.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly available information on planned lifeguard patrol locations and timing
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Unavailability of professional lifeguard cover on Cornwall beaches
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” Open source report
×
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 and expand summer RNLI lifeguard coverage by working with landowners and councils to confirm additional beach cover.
Verbatim wording from the response “Our original plan was to have lifeguard patrols on 70 beaches this summer. It was a conservative plan and made and announced when many things were still unknown. We now have a better idea of the journey out of lockdown for all parts of the UK, understand the new regulations with which we must comply as an employer and service provider and, most importantly, feel we can properly manage the risks associated with coronavirus. We were on 18 beaches last weekend, 8 of which are in Cornwall, and we are revising our original plans and exploring which additional beaches we can lifeguard this summer. To this end, we are working hard with 55 landowners and local councils to ensure as many beaches as possible will have RNLI lifeguard cover.” Source location 2020-0121-Response-from-RNLI_Redacted.pdf
Open published response
×
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 Make public announcements detailing confirmed beaches and timings for the lifeguard-service rollout.
Verbatim wording from the response “With so many local landowners to work with, and so many dependencies, it will take time to confirm individual beaches and timings, but we will make public announcements more detail over the next few weeks.” Source location 2020-0121-Response-from-RNLI_Redacted.pdf
Open published response
×
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 Landowners, rather than the RNLI, are responsible for assessing public beach-use risks and providing or arranging lifeguarding.
Verbatim wording from the response “I appreciate your concerns about the prevention of future deaths. Further, I also appreciate that in accordance with Chief Coroner’s Guidance No. 5, you may issue a Regulation 28 Report before an inquest is concluded. However, in this instance I believe the Regulation 28 Report is premature and has been made without the benefit of all the relevant information; this includes the fact it is the landowner, not the RNLI, who has the responsibility to carry out risk assessments covering the public use of beaches, and then to mitigate the risks they identify by, amongst other things, providing a lifeguarding service.” Source location 2020-0121-Response-from-RNLI_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The deaths cannot yet be attributed to the absence of lifeguards because the inquest must determine causation.
Verbatim wording from the response “As you set out in paragraph 5 of your report, your request is based upon the fact you believe that, unless lifeguarding services are back on beaches, there will inevitably be a further loss of life. This pre-supposes that both deaths were caused by a lack of lifeguards, which of course will require an inquest to determine.” Source location 2020-0121-Response-from-RNLI_Redacted.pdf
Open published response
Concerns raised 2 Unavailability of public information on planned beach patrol locations and timing View source Lack of professional lifeguard cover on Cornwall’s beaches 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
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Davey, aged 17, was trapped under a capsized pleasure craft near Padstow and could not be resuscitated. On the same day, Michael Pender, aged 63, was rescued after apparently being caught in a rip current while swimming off Treyarnon Bay, but could not be resuscitated. The principal concern was that no Cornish beach had lifeguard cover that day and that beaches remained unguarded, with a fear of further loss of life until professional lifeguard services returned.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Unavailability of public information on planned beach patrol locations and timing
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of professional lifeguard cover on Cornwall’s beaches
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” Open source report
24 Jul 2017 GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Visitors’ language difficulties and lack of experience with the sea View source Failure to maintain effective public communication about coastal safety View source Lack of formal governance and control of coastal risk management View source Insufficient education and awareness of coastal dangers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Use fatality data and root-cause analysis to update national, local and targeted drowning-prevention messaging, while developing improved data analysis and impact metrics.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023. View source
Action
Provide and continue the Camber Sands lifeguard service, including face-to-face beach-safety information and literature, when requested and supported by the local authority.
Stated completedThe respondent said that this action was complete when they made their response on 27 March 2023. View source
Action
Deliver and expand education and awareness programmes for children and others about coastal and inland-water dangers through staff, volunteers and partner organisations.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023. View source
Action
Identify at-risk groups, including people facing ethnic or language barriers, and determine effective ways to communicate safety messages to them.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 March 2023. View source
Action
Deliver beach-safety communications through digital platforms, modern advertising and face-to-face methods, while monitoring effectiveness and coordinating resources with other organisations.
Stated completedThe respondent said that this action was complete when they made their response on 27 March 2023. View source
Action
Carry out free beach risk assessments for local authorities, landowners and beach operators to inform decisions about lifeguard provision and risk controls.
Stated completedThe respondent said that this action was complete when they made their response on 27 March 2023. View source See 3 more actions
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AI-generated summary
GUSTAVO SILVA DA CRUZ and 6 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 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Visitors’ language difficulties and lack of experience with the sea
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea . The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective public communication about coastal safety
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process ,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of formal governance and control of coastal risk management
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements . Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime , given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient education and awareness of coastal dangers
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea .
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report
×
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 fatality data and root-cause analysis to update national, local and targeted drowning-prevention messaging, while developing improved data analysis and impact metrics.
Verbatim wording from the response “Action taken - The RNLI draws on fatality data and its root cause analysis from the National Water Safety Forum’s (NWSF) Water Incident Database (WAID). The evidence from that database (and from our own and open source data) helps inform the content of our annual national drowning prevention campaign known as ‘Respect the Water’. Learning also informs local campaigns and targeted messages to ‘at risk’ groups. This action has been underway for a number of years and also delivered through our membership of the NWSF, our support of the National Drowning Prevention Strategy and our other partnership and influencing work at national and local level. Specifically, our campaign and messages content is updated on a continuous review basis, with improved data collection/analysis and impact metrics under development.” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 and continue the Camber Sands lifeguard service, including face-to-face beach-safety information and literature, when requested and supported by the local authority.
Verbatim wording from the response “Action taken - The RNLI’s charitable activity to improve safety at Camber Sands has led to the provision of a 2017 lifeguard service there which we are able to provide next year and into the future on the proviso that Rother District Council requests us to and supports our service. This service includes offering face to face beach safety information and literature as well. Other aspects of beach safety there are informed by the risk assessment and we believe it is for them to ensure the necessary resource is available to implement the identified risk control measures.” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 and expand education and awareness programmes for children and others about coastal and inland-water dangers through staff, volunteers and partner organisations.
Verbatim wording from the response “Education and awareness of coastal dangers” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Identify at-risk groups, including people facing ethnic or language barriers, and determine effective ways to communicate safety messages to them.
Verbatim wording from the response “Ethnic and language barrier considerations” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 beach-safety communications through digital platforms, modern advertising and face-to-face methods, while monitoring effectiveness and coordinating resources with other organisations.
Verbatim wording from the response “Communication” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Carry out free beach risk assessments for local authorities, landowners and beach operators to inform decisions about lifeguard provision and risk controls.
Verbatim wording from the response “In order to determine where lifeguard units should be provided and for what season length, the RNLI has developed a beach risk assessment service that is free to local authorities, land owners and beach owners/operators. However, the risk assessment and the outcome recommendations are purely advisory. It is for the local authority, land owner or beach owner/operator to then decide whether to implement the recommendations. There is no legal” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 There are no enforcement powers concerning implementation of the RNLI’s beach risk-assessment recommendations.
Verbatim wording from the response “obligation for the RNLI to provide the risk assessment service and we do not have any enforcement powers concerning whether its recommendations are implemented.” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Those responsible for beaches must provide resources and implement the control measures identified by risk assessments.
Verbatim wording from the response “Action taken - The RNLI’s charitable activity to improve safety at Camber Sands has led to the provision of a 2017 lifeguard service there which we are able to provide next year and into the future on the proviso that Rother District Council requests us to and supports our service. This service includes offering face to face beach safety information and literature as well. Other aspects of beach safety there are informed by the risk assessment and we believe it is for them to ensure the necessary resource is available to implement the identified risk control measures.” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Local authorities, landowners and beach owners or operators decide whether to implement advisory risk-assessment recommendations.
Verbatim wording from the response “In order to determine where lifeguard units should be provided and for what season length, the RNLI has developed a beach risk assessment service that is free to local authorities, land owners and beach owners/operators. However, the risk assessment and the outcome recommendations are purely advisory. It is for the local authority, land owner or beach owner/operator to then decide whether to implement the recommendations. There is no legal” Source location Response from Royal National Lifeboat Institution
Open published response
×
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 Formal governance of beach-safety risk management cannot be examined on behalf of the nation.
Verbatim wording from the response “Action taken - The RNLI is not in a position to examine the formal governance of beach safety risk management on behalf of the nation. We would welcome a review and believe that local authorities, landowners and beach owners/operators should have a more clearly defined obligation for the risk management of their beaches and to act on risk assessment outcomes. This, in our opinion would reduce the likelihood of accidental drowning occurring in the beach environment.” Source location Response from Royal National Lifeboat Institution
Open published response
4 Nov 2014 Rebecca Jodie CURTIS-SMALL · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 2 Failure to provide signage warning of specific riptide hazards under varying tide conditions View source Failure to ensure easily visible appropriate signage at each beach entrance 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
Rebecca Jodie CURTIS-SMALL · 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
Rebecca Jodie CURTIS-SMALL was caught by a rip tide while swimming with her family at Croyde Bay on 31 December 2013. She was found after a search, taken to hospital, and died from drowning and hypothermia; concerns related to the visibility and specificity of beach signage warning about rip-tide hazards.
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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to provide signage warning of specific riptide hazards under varying tide conditions
Wider context from the report “1. That the appropriate signage is displayed in a way that can easily be seen on each of the entrances to the beach.
2. Whether the sign could refer to any specific riptide hazards known of at the beach in order to warn members of the public using the beach at different times of the year and different states of the tide, that rip tides would be more hazardous .
” 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 Royal National Lifeboat Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure easily visible appropriate signage at each beach entrance
Wider context from the report “1. That the appropriate signage is displayed in a way that can easily be seen on each of the entrances to the beach .
2. Whether the sign could refer to any specific riptide hazards known of at the beach in order to warn members of the public using the beach at different times of the year and different states of the tide, that rip tides would be more hazardous.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations