Recipient

Somerset Council

First report 1 Aug 2013•Latest report 19 Sep 2024

Recipient record

Reports, concerns and published responses

Local government · English unitary authority. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 25%
Concerns addressed: 1
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

25%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Sep2024
Somerset
Concerns raised1
1. Failure to prominently and clearly display water-entry risks and undercurrent and rip-tide dangers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review safety signage provision at Burnham-on-Sea Jetty.
  Stated completed
2. Action
  Complete lower-jetty line painting warning against access because of dangerous currents.
  Stated in progress
3. Action
  Install prominent entrance signage warning of strong currents and drowning or injury risks.
  Stated in progress
1. Action
  Install signage at the Jetty, including top-of-jetty signs and line markings on the tarmacked surface.
  Stated completed
AI-generated summary

Peter Ivor Jeffery · 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

Peter Ivor Jeffery, aged 68, entered the water at Burnham-on-Sea on 29 October 2023 to assist a stranger and her dog in distress and was overcome by a rip tide. He was unable to be rescued and his body was discovered near Stert Island on 12 November 2023. The report raises concerns that the risks of entering the water, including undercurrents and rip tides, were not prominently and clearly displayed to people without local knowledge, particularly outside the season when additional signage or flags were absent.

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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to prominently and clearly display water-entry risks and undercurrent and rip-tide dangers
Wider context from the report
“Whilst there are multiple signs in existence at the location, not all of these are for public safety, some focus on more ‘administrative’ matters such as the closure of gates and the prohibition of parking on the jetty. Whilst this issues are undoubtedly important in the smooth administration of the public space, the consequences of such are not life threatening and the size and prominence of such administrative signs and surprising when compared with the signage that conveys potentially life-saving information. I am concerned that the risks posed by entering the water (which appear equal to, if not greater than, the risks posed by the mud and sand) are not prominently and clearly displayed to those who lack local knowledge, especially out of ‘season’. This may cause people to misinterpret or underestimate the dangers posed by the undercurrent and rip-tides which, of course, are under the surface of the water and so not immediately obvious or visible. As such people may continue to make ill-advised decisions to enter the water; water which has the power and ability to overwhelm even the strongest of adult swimmers within seconds. ”
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
Review safety signage provision at Burnham-on-Sea Jetty.

Verbatim wording from the response
“Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

Source location
Response from Somerset Council
Page 2 · response
Published 19 September 2024
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
Complete lower-jetty line painting warning against access because of dangerous currents.

Verbatim wording from the response
“In addition, line painting is being completed on the lower part of the jetty advising against access stating “Dangerous Currents no Access””

Source location
Response from Somerset Council
Page 2 · response
Published 19 September 2024
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
Install prominent entrance signage warning of strong currents and drowning or injury risks.

Verbatim wording from the response
“Somerset Council has reviewed the provision of safety signage at Burnham on Sea Jetty. In order to address the concerns that have been raised Somerset Council is installing additional safety signage at Burnham on Sea Jetty. This new signage specifically and clearly highlights the risks associated with the strong currents that occur around the jetty. This signage is to be displayed prominently at the entrance to the jetty.”

Source location
Response from Somerset Council
Page 2 · response
Published 19 September 2024
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
Install signage at the Jetty, including top-of-jetty signs and line markings on the tarmacked surface.

Verbatim wording from the response
“I refer to my letter dated the 11 November 2024. As discussed in my letter of the 11 November 2024 I have attached below details of the signage installed at the Jetty in Burnham on Sea. This work was completed in November 2024. This has involved signage being installed at the top of the jetty and line marked signage being applied to the tarmacked surface”

Source location
Updated response from Somerset Council
Page 1 · response
Published 19 September 2024
Open published response
4 Oct2017
Somerset
Concerns raised6
1. Delays in access to CBT
2. Failure to urgently contact the school about the need for psychiatric input
3. Insufficient detail in care plans to record safeguarding requirements
1. Failure to obtain urgent psychiatric input
2. Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
3. High threshold for CAMHS referral
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

Sofia Ann Legg · 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

Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.

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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Delays in access to CBT
Wider context from the report
“2. Availability of CBT. Sofia was placed on a 6 month waiting list for CBT. This delay appears considerable. ”
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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to urgently contact the school about the need for psychiatric input
Wider context from the report
“4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia. ”
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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Insufficient detail in care plans to record safeguarding requirements
Wider context from the report
“4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia. ”
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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain urgent psychiatric input
Wider context from the report
“3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance. ”
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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
Wider context from the report
“5. Language used in the SIRI Report was felt to be inappropriate. The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome. I do not believe either of these statements were true. ”
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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
High threshold for CAMHS referral
Wider context from the report
“1. Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy has been of positive benefits to Sofia. ”
Open source report
24 Oct2016
Somerset
Concerns raised1
1. Failure to ensure review of maximum vehicle speed following accident-history signage
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

Sally Frances Eveleigh · 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

Sally Frances Eveleigh, aged 70, died after her vehicle pulled out onto the A358 at the junction with Station Road and collided with a van. The concern was whether a sign indicating previous accidents at the junction should also have prompted a review of the maximum speed for approaching vehicles.

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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure review of maximum vehicle speed following accident-history signage
Wider context from the report
“The location of this collision was the junction of Station Road with the A358 at Bishops Lydeard. I heard evidence at the inquest that a roundabout had been proposed at this junction for a number of years and that by the time the inquest commenced works were about to start. My concern is that there was a sign erected at this junction indicating that there had been a number of accidents at the junction previously but I was concerned as to whether the erection of such a sign would also necessarily involve a review of maximum speed for vehicles approaching such a junction. ”
Open source report
1 Aug2013
West Somerset
Concerns raised1
1. Risk of vehicle occupants drowning after vehicles leave carriageways and land in rhynnes
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

Michael James THORNTON · 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

Michael James THORNTON was a front-seat passenger in a Land Rover that left the carriageway after swerving to avoid a deer and entered an adjoining rhyne. He was later pulled from the vehicle, and the inquest recorded drowning, reduced consciousness, traumatic head injury and ethanol ingestion; the concern was that vehicles leaving carriageways and landing in rhynes regularly resulted in occupants drowning.

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 Somerset Council; that does not assign responsibility.
PFD Monitor interpretation
Risk of vehicle occupants drowning after vehicles leave carriageways and land in rhynnes
Wider context from the report
“That I have between one and two deaths per year from vehicles leaving the carriageway and landing in a rhy nne, often resulting in the death of the occupant by drowning and therefore some action should be taken to prevent future death. Although the erection of retaining barriers along the sides of any carriageway to adjoining rhynnes might prevent future accidents, the cost would be prohibitive and well beyond resources of the County Council, given that there must be between 100 and 200 miles of roadway to be protected. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to prominently and clearly display water-entry risks and undercurrent and rip-tide dangers

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.4

Concerns raised6

Delays in access to CBT

Failure to urgently contact the school about the need for psychiatric input

Insufficient detail in care plans to record safeguarding requirements

Failure to obtain urgent psychiatric input

Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change

High threshold for CAMHS referral

Concerns raised1

Failure to ensure review of maximum vehicle speed following accident-history signage

Concerns raised1

Risk of vehicle occupants drowning after vehicles leave carriageways and land in rhynnes

Actions described in response 4