Somerset Council

Local government · English unitary authority

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First report 1 Aug 2013•Latest report 19 Sep 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
4

Naming this recipient

Published responses
25%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
4

Described in responses

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.

  1. Addressed to Sedgemoor District Council, now represented here by Somerset Council.

    Somerset

    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

  2. Addressed to Somerset County Council, now represented here by Somerset Council.

    Somerset

    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

  3. Addressed to Taunton Deane Borough Council, now represented here by Somerset Council.

    Somerset

    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

  4. West Somerset

    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
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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