18 Jul 2025 David Joseph HAYES · Prevention of Future Deaths report Manchester West
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Concerns raised 4 Failure of washing detergent containers to restrict access by vulnerable adults or children View source Insufficient labelling warnings about risks to vulnerable adults and children View source Washing detergent packaging resembling items that vulnerable adults may confuse it with View source Lack of public awareness of the need to safeguard detergents from vulnerable adults View source See 1 more concern
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AI-generated summary
David Joseph HAYES · 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 Joseph HAYES, who had dementia, accidentally ingested washing detergent after confusing its packaging with a milk carton. He subsequently suffered vomiting, aspiration and pneumonitis, and died on 21 April 2025. The principal concerns were the detergent’s packaging and colouring, its accessible screw-top lid, and whether labelling and public awareness adequately addressed risks to vulnerable adults.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure of washing detergent containers to restrict access by vulnerable adults or children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Insufficient labelling warnings about risks to vulnerable adults and children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children .
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Washing detergent packaging resembling items that vulnerable adults may confuse it with
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of the need to safeguard detergents from vulnerable adults
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote safe household chemical storage through guidance and public messaging, including original containers, separation from food and medicines, and marked cupboards.
Verbatim wording from the response “Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.” Source location Response from RoSPA
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 Develop practical guidance for carers on safely storing and handling hazardous household substances.
Verbatim wording from the response “• The development of practical guidance for carers on safer storage of these products within the home.” Source location Response from RoSPA
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a national social media campaign raising awareness of household chemical risks for people with dementia.
Verbatim wording from the response “• A targeted social media campaign to raise awareness about the risks posed by household chemicals to those with cognitive impairment” Source location Response from RoSPA
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 Engage manufacturers and regulators to encourage packaging that avoids food or drink resemblance and clearer warnings addressing risks to vulnerable adults.
Verbatim wording from the response “Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.” Source location Response from RoSPA
Open published response
7 Nov 2024 Daniel PINKNEY · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Lack of Highway Code guidance on aquaplaning 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
Daniel PINKNEY · 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
Daniel PINKNEY died after his vehicle aquaplaned on surface water while travelling on the A164 on 19 December 2022, crossed into the opposite carriageway and collided with another vehicle. The principal concern was the need for greater awareness of aquaplaning, reduced speed when surface water is present, and basic knowledge of braking and steering; it was noted that the Highway Code was silent on this matter.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of Highway Code guidance on aquaplaning
Wider context from the report “I believe that greater awareness of the phenomenon of aquaplaning is important, together with the need to reduce speed when surface water is present, coupled with basic knowledge about braking and steering, should a vehicle experience this phenomenon. I was informed by a forensic collision expert that the Highway Code is at present silent on this matter but road user should be familiar with it.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and share digital education materials on aquaplaning awareness through social media and the RoSPA website.
Verbatim wording from the response “Actions to be taken by RoSPA
Your report highlights the issue of aquaplaning, and the risks associated with driving through surface water. In response to your concerns, we outline below the actions RoSPA intends to advocate for to enhance road safety and reduce the risk of similar incidents in the future:” Source location Response from ROSPA
Open published response
Concerns raised 1 Ongoing foreseeable risk of cigarette-related fires in vulnerable individuals permitted to smoke on the premises 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
Raymond BRATTLEY · 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
Raymond BRATTLEY, a heavy cigarette smoker, died at the scene on 8 January 2024 after a fire caused by careless smoking engulfed him in his flat, causing widespread full-thickness burns. The report raises concerns about the risk of cigarette-related fires involving vulnerable people and the potential value of seeking Fire Service advice and considering measures such as metal wastepaper bins and fire-retardant materials.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Ongoing foreseeable risk of cigarette-related fires in vulnerable individuals permitted to smoke on the premises
Wider context from the report “It was known to the staff at Portland Mews that this gentleman was a heavy smoker and that on a number of previous occasions, he set fire to waste paper bins in his flat as well as burning himself, carpets and soft furnishings due to careless smoking. On all previous occasions, the fires were contained or extinguished. Appropriate action was taken by the staff in respect of this issue. However, in the most general of terms, evidence was heard from a fire investigator, that if issues of this nature arise in other organisations or care settings, they should be brought to the attention of the Fire Service, who would freely provide advice about ways in which to mitigate the ongoing and foreseeable risk of cigarette related fires occurring in other vulnerable individuals . Such measures might include the provision of metal wastepaper bins and the use of fire-retardant materials. It is recognised that in similar institutions, tenants are permitted to smoke on such premises, but there is a tension between allowing smoking on the premises and risk of fires occurring, particularly in vulnerable individuals who may have similar mobility problems to Mr Brattley .
” Open source report
Concerns raised 4 Failure to provide sufficiently prominent warnings about full-face mask risks to affected users View source Lack of medical-profession awareness and training on Immersion Pulmonary Oedema View source Failure of mask safety testing to replicate general-public use conditions View source Lack of applicable standards for full-face snorkelling masks View source See 1 more concern
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
Angela Jean Kearn · 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
Angela Jean Kearn, aged 63, collapsed and died while snorkelling in Egypt on 13 January 2020. The inquest identified immersion pulmonary oedema as the cause of death, with hypertension, hormone replacement therapy and use of a full-face snorkel mask each contributing more than minimally. Concerns included limited medical awareness of immersion pulmonary oedema and insufficiently publicised safety warnings about using full-face snorkel masks with cardiovascular or respiratory conditions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently prominent warnings about full-face mask risks to affected users
Wider context from the report “ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner.” The same additional wording is being translated and added to all websites of the company.
x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions.
xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks . Those purchased before 2017 had no warning in relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of medical-profession awareness and training on Immersion Pulmonary Oedema
Wider context from the report “Awareness of Immersion Pulmonary Oedema in the medical profession:
i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training , as a consequence, it can be missed by those treating the condition and is often mistaken for drowning.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure of mask safety testing to replicate general-public use conditions
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask.
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public .
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of applicable standards for full-face snorkelling masks
Wider context from the report “The Full Face Mask
ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask .
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public.
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time .
” Open source report
15 Feb 2019 Dwayne Daniel Ryan Thompson · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to maintain effective physical access controls at reservoirs View source Failure to design reservoir risk signage for people with learning disabilities 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
Dwayne Daniel Ryan Thompson · 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
Dwayne Daniel Ryan Thompson went swimming at the Reservoir at Audenshaw on 28 June 2018, got into difficulties, went underwater, and later died in hospital after suffering a catastrophic brain injury. The inquest heard that the reservoir’s fence was regularly damaged and that its warning signs, although compliant with HSE guidance, had not been shown to take account of the needs and understanding of people with learning disabilities.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective physical access controls at reservoirs
Wider context from the report “The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim in/cool down in during the heat of the summer. It was unusual in having a fence and the majority of reservoirs were easily accessible by the public . There was signage to warn of the risks of swimming in reservoirs. This signage was used across all reservoirs including those with open access to them. It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when they were devised.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to design reservoir risk signage for people with learning disabilities
Wider context from the report “The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim in/cool down in during the heat of the summer. It was unusual in having a fence and the majority of reservoirs were easily accessible by the public. There was signage to warn of the risks of swimming in reservoirs. This signage was used across all reservoirs including those with open access to them. It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when they were devised .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for managing risks to members of the public rests legally with the reservoir duty holder.
Verbatim wording from the response “Risk management and warning signage for the public
Under UK health and safety law, it is incumbent upon the duty holder to maintain a system which identifies and manages risks to those affected by the workplace. RoSPA would expect the drowning of a member of the public at a reservoir to be a foreseeable risk. The question of how this is subsequently managed, by law, rests with the duty holder. We publish specialist, collectively agreed guidance to assist with these decisions. Further, we have previously assisted Water UK in the production of their guidance for reservoir safety.” Source location 2019-0055-Response-by-RoSPA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RoSPA has no regulatory role or enforcement powers concerning reservoir safety management.
Verbatim wording from the response “Background
The Royal Society for the Prevention of Accidents (RoSPA) is a charity in existence for over a century, we are concerned with the prevention of accidents across the full range of life, both in the UK and abroad. RoSPA has no regulatory role, or enforcement powers.” Source location 2019-0055-Response-by-RoSPA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RoSPA cannot comment on measures at the location because it has not visited the site.
Verbatim wording from the response “The following responses are that of RoSPA. We have not visited the location in question and offer no commentary with respect to measures in place. Our key actions are numbered to the structure of your letter.” Source location 2019-0055-Response-by-RoSPA
Open published response
Concerns raised 11 Lack of national reinforcement of paediatric assessment for young children View source Lack of understanding of button-battery risks among people responsible for small children View source Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service View source Failure to sustain and nationally reinforce the button-battery safety alert View source Failure to follow the policy for children under 5 View source Failure to complete or fully document child assessments View source Lack of POAU audit systems for detecting noncompliance View source Lack of understanding of the risks of subjective assessments in young children View source Failure to follow the POAU system View source Failure to value-check subjective assessments in young children View source Lack of child-resistant safety features for button batteries in commonly used household devices View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Venkata Naga Lakshyasi KAGGA · 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
Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of national reinforcement of paediatric assessment for young children
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of button-battery risks among people responsible for small children
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
Wider context from the report “7. The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to sustain and nationally reinforce the button-battery safety alert
Wider context from the report “2. NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved . The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work had taken place .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy for children under 5
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or fully document child assessments
Wider context from the report “5. The importance of carrying out a full assessment of a child or documenting fully why it was not carried out on 6ᵗʰ July was not recognised by the medical staff involved .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of POAU audit systems for detecting noncompliance
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the risks of subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the POAU system
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Failure to value-check subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata . The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of child-resistant safety features for button batteries in commonly used household devices
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” 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.
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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 The Royal Society For The Prevention Of Accidents; 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 The Royal Society For The Prevention Of Accidents; 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 The Royal Society For The Prevention Of Accidents; 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 The Royal Society For The Prevention Of Accidents; 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
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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 Standardise safety-information campaigns within the National Water Safety Forum and make campaign resources readily available to beach and other managers.
Verbatim wording from the response “Within the NWSF, steps have been taken to standardise and collectively approach safety information campaigns, and to make readily available these resources to beach and other managers.” Source location Response from RoSPA
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 UK and international standardised water-safety signs and symbols requiring minimal language knowledge.
Verbatim wording from the response “Steps we have already taken include:” Source location Response from RoSPA
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 Produce collective UK interpretation guides explaining how to implement standardised water-safety signs and symbols.
Verbatim wording from the response “• The production of collective interpretation guides for the UK on “how to implement” these standards” Source location Response from RoSPA
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 Regulatory and enforcement action is outside the organisation’s authority because it has no regulatory or enforcement powers.
Verbatim wording from the response “The Royal Society for the Prevention of Accidents (RoSPA) is a national charity, currently marking its centenary, with no regulatory or enforcement powers. Our approach, within the existing structures for water safety, is to seek to influence, inform, coordinate activity and advise. A considerable amount of our resources are spent seeking to engage with government departments and local authorities to bring a coherent and focused approach to tackling the burden of drowning.” Source location Response from RoSPA
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 A review of coastal and beach water safety advice is contingent on available resources.
Verbatim wording from the response “(iv) RoSPA is currently revising its water safety advice for owners and duty-holders of inland waters. Subject to resources, we will look to review the equivalent advice for coastal and beach environs by the end of 2018.” Source location Response from RoSPA
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 Studying ethnicity and language as drowning factors is constrained because these characteristics are not routinely recorded at inquests.
Verbatim wording from the response “The extent to which ethnicity and language skills are a factor in drowning has not been quantified in the UK. We are currently exploring the feasibility of studying these factors. However, it is our understanding that information on these are not routinely recorded at Inquest.” Source location Response from RoSPA
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 Government should clarify national duties, while local authorities and other duty-holders determine and manage local water safety risks.
Verbatim wording from the response “In order to facilitate this learning, we believe action is required nationally by Government, particularly the clarification of duties held primarily by local authorities.” Source location Response from RoSPA
Open published response
Concerns raised 2 Lack of a seat belt alarm to alert carers to seat belt disengagement View source Unrestrained passengers following seat belt disengagement 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
William PIERCY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William PIERCY died at Hull Royal Infirmary on 25 July 2013 from pneumonia resulting from an injury sustained in a road traffic collision four days earlier. The principal concern was that his seat belt had become disengaged, leaving him unrestrained and allowing him to be thrown forward and fracture his neck; a seat belt alarm might have alerted carers to the disengagement.
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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of a seat belt alarm to alert carers to seat belt disengagement
Wider context from the report “(1) Seat belt was disengaged thereby allowing a passenger to be unrestrained and when vehicle came to an abrupt halt, he was thrown forward and fractured his neck. A seat belt alarm would have alerted his carers to the disengagement of the seat belt .
” 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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Unrestrained passengers following seat belt disengagement
Wider context from the report “(1) Seat belt was disengaged thereby allowing a passenger to be unrestrained and when vehicle came to an abrupt halt, he was thrown forward and fractured his neck. A seat belt alarm would have alerted his carers to the disengagement of the seat belt.
” Open source report
Concerns raised 1 Lack of compulsory suitable protective helmet use on motorised bicycles capable of exceeding 15 MPH View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Donald Spooner · 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
Donald Spooner died after being thrown from a motorised bicycle when it caught the edge of a parked vehicle. He was not wearing a protective helmet, and the report raised concerns that helmet use was not compulsory for motorised bicycles capable of speeds over 15 MPH and that protective headgear might have reduced his injuries.
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 The Royal Society For The Prevention Of Accidents; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory suitable protective helmet use on motorised bicycles capable of exceeding 15 MPH
Wider context from the report “1. That it is not compulsory to wear a suitable protective helmet whilst travelling on a motorised bicycle which can reach speeds in excess of 15 MPH
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand RoSPA’s website cycle-safety advice to include motorised bicycles.
Verbatim wording from the response “As a charity with limited resources, we have to prioritise the campaigns we conduct. Therefore, RoSPA’s approach as far as cycle helmets are concerned is to raise awareness about them and to promote their use through our wide range of communication methods. We publish a range of cycle safety advice on our website, and we will expand this to include motorised bicycles. We will also, when appropriate, include these messages in our safety journals and in our communications on social media networks such as twitter. The Highway Code provides cycle safety advice, and the next time it is being reviewed we will suggest it includes specific advice about motorised bicycles.” Source location 2014-0208-Response-by-the-ROSPA
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 Suggest including specific motorised-bicycle safety advice when the Highway Code is next reviewed.
Verbatim wording from the response “As a charity with limited resources, we have to prioritise the campaigns we conduct. Therefore, RoSPA’s approach as far as cycle helmets are concerned is to raise awareness about them and to promote their use through our wide range of communication methods. We publish a range of cycle safety advice on our website, and we will expand this to include motorised bicycles. We will also, when appropriate, include these messages in our safety journals and in our communications on social media networks such as twitter. The Highway Code provides cycle safety advice, and the next time it is being reviewed we will suggest it includes specific advice about motorised bicycles.” Source location 2014-0208-Response-by-the-ROSPA
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 RoSPA cannot campaign for mandatory requirements because necessary data about motorised bicycles, usage and injuries is unavailable.
Verbatim wording from the response “We know from our experience of many years of campaigning for legal changes just how difficult it can be to persuade government and Parliament to act, even when we have clear data on the potential casualty savings. I do not believe the necessary data (i.e. the exact type of bicycle that would be captured by such a law and how easy it would be for the police to identify it from normal bicycles, the numbers being used and the number and type of injuries suffered by their users) exists in relation to motorised bicycles. It is highly unlikely that the government would be prepared to introduce a mandatory cycle helmet law covering a specific type of bicycle.” Source location 2014-0208-Response-by-the-ROSPA
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 RoSPA does not support mandatory helmet laws because enforcement would require significant police resources and could discourage cycling.
Verbatim wording from the response “However, RoSPA has not called for a compulsory cycle helmet law because voluntary wearing rates are still too low and it would require a significant enforcement effort by the police. Also, it is not clear whether such a law would discourage people from cycling, thereby losing the significant health and environmental benefits from cycling. These benefits are why promoting cycling has become an important public health policy, with significant investment, in recent years.” Source location 2014-0208-Response-by-the-ROSPA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RoSPA prioritises campaigns due to limited resources and therefore will promote helmet use rather than conduct legislative campaigning.
Verbatim wording from the response “As a charity with limited resources, we have to prioritise the campaigns we conduct. Therefore, RoSPA’s approach as far as cycle helmets are concerned is to raise awareness about them and to promote their use through our wide range of communication methods. We publish a range of cycle safety advice on our website, and we will expand this to include motorised bicycles. We will also, when appropriate, include these messages in our safety journals and in our communications on social media networks such as twitter. The Highway Code provides cycle safety advice, and the next time it is being reviewed we will suggest it includes specific advice about motorised bicycles.” Source location 2014-0208-Response-by-the-ROSPA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RoSPA lacks authority to introduce legislation, although it can campaign for legislative change.
Verbatim wording from the response “As a charity, RoSPA has no power to introduce legislation of any kind, but we can, of course, campaign for changes to legislation, as we have done on many occasions. However, we always consider the evidence for the need, costs and likely effectiveness of a new safety law before campaigning for it to be introduced.” Source location 2014-0208-Response-by-the-ROSPA
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations