30 Jan 2025 Alex Edward CROOK · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Failure to site throw lines at obvious water entry points View source Failure to site water-safety signs close to obvious water entry points View source Failure to deliver statutory swimming lessons at key stages 1 and 2 View source Failure of water-safety signs to state no unauthorised swimming View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alex Edward CROOK · 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
Alex Edward Crook, aged 15, drowned after going out of his depth while playing at the edge of Scotsmans Flash on 7 September 2024. The concerns included failures to provide statutory swimming lessons, inadequate wording and siting of warning signs, and proposed siting of throw lines away from obvious water entry points.
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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to site throw lines at obvious water entry points
Wider context from the report “It was established in evidence that throw lines are the most effective life-saving equipment. It was noted that the proposal is to locate these away from obvious entry points . This would seem to be likely to make them less effective than if they were sited at the more obvious entry points . The need for such equipment, as with the signage, is urgent.
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to site water-safety signs close to obvious water entry points
Wider context from the report “I am informed that signs have been erected as recently as 29 January 2025 at Scotsmans Flash yet these do not contain the words "no unauthorised swimming". It was agreed in evidence that if such signs were erected expeditiously close to the obvious entry points to the water , it might deter such use.
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver statutory swimming lessons at key stages 1 and 2
Wider context from the report “He did not have statutory swimming lessons at key stage 1 or 2 and I am informed that three schools in Wigan area still in breach of statutory duty to deliver such lessons .
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of water-safety signs to state no unauthorised swimming
Wider context from the report “I am informed that signs have been erected as recently as 29 January 2025 at Scotsmans Flash yet these do not contain the words "no unauthorised swimming" . It was agreed in evidence that if such signs were erected expeditiously close to the obvious entry points to the water, it might deter such use.
” 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 Install enlarged warning and prohibition signs covering all viable approaches to Scotman’s Flash.
Verbatim wording from the response “In respect of the signage, five signs have now been installed at Scotman’s Flash, which clearly and visibly warn the public of the dangers of deep water and cold-water shock. All viable approaches to Scotman’s Flash have now been covered by appropriate signage, these signs are much larger than previous signs. It was also agreed during the site inspection that supplementary prohibition signage including the wording “No unauthorised swimming or boating” will be added to the current signs. The prohibition signage has been produced and installed at Scotman’s Flash.” Source location Response from Wigan Metropolitan Borough Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify further support for swimming lessons for schools and young people.
Verbatim wording from the response “I can confirm that the three schools in the Wigan area that had not provided swimming lessons at the time of the inquest have now all engaged and have booked swimming lessons. Furthermore, Mabs Cross Primary School, which is the primary school Alex attended having engaged in school swimming lessons with the Council for over 20 years and Alex’s class did engage in lessons when Alex was a pupil at the school. The WWSP also agreed an action to identify further support for swimming lessons for schools and young people. Common barriers to accessing swimming lessons tend to include class sizes, lack of year 6 mop up sessions, parental consent needed for attendance, transport costs and funding for high school swimming lessons, all of which are being considered by the WWSP in respect of a potential local pilot for free swimming lessons for young people within the borough.” Source location Response from Wigan Metropolitan Borough Council
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 Write to local authority-aided primary schools reminding them of their statutory swimming-lesson obligations.
Verbatim wording from the response “The WWSP met on 27th February 2025 and one of the actions from this meeting was that a letter was to be sent to all local authority aided primary schools in the Wigan borough in respect of the provision of swimming lessons. The duty to provide swimming lessons in primary schools as part of the National Curriculum is imposed on schools. Academies are not required to follow the National Curriculum, so therefore are not under a duty to provide swimming lessons. Local authorities are under a duty to promote high standards of education but the responsibility to ensure that the National Curriculum is provided lies with the individual schools. I can confirm that the Local Authority has written to all local authority aided schools within the Wigan Borough to remind them of the school’s obligations, as part of the National Curriculum, to provide swimming lessons for pupils.” Source location Response from Wigan Metropolitan Borough Council
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 three throwline boards at the agreed locations, including one repositioned nearer likely swimming locations.
Verbatim wording from the response “A Throwline board
B Throwline board
C Throwline board” Source location Response from Wigan Metropolitan Borough Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for ensuring National Curriculum swimming provision rests with individual schools, not the local authority.
Verbatim wording from the response “The WWSP met on 27th February 2025 and one of the actions from this meeting was that a letter was to be sent to all local authority aided primary schools in the Wigan borough in respect of the provision of swimming lessons. The duty to provide swimming lessons in primary schools as part of the National Curriculum is imposed on schools. Academies are not required to follow the National Curriculum, so therefore are not under a duty to provide swimming lessons. Local authorities are under a duty to promote high standards of education but the responsibility to ensure that the National Curriculum is provided lies with the individual schools. I can confirm that the Local Authority has written to all local authority aided schools within the Wigan Borough to remind them of the school’s obligations, as part of the National Curriculum, to provide swimming lessons for pupils.” Source location Response from Wigan Metropolitan Borough Council
Open published response
2 Dec 2019 Sidney Clarence Baker · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to maintain accurate and adequate care records View source Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sidney Clarence Baker · 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
Sidney Clarence Baker, a frail elderly man with multiple co-morbidities, died at the Royal Albert Edward Infirmary in Wigan after a deterioration in health and treatment for acute kidney injury following a fall. The report raised concerns that required dietician and falls-team referrals were not documented, and that care-plan entries, including weight-monitoring information, were incorrect and record keeping was generally poor.
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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and adequate care records
Wider context from the report “2. There were concerns that entries contained in Mr Baker's care plan were incorrect , including vital information contained on his weight monitoring sheet . Furthermore, the general quality of record keeping was poor .
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals
Wider context from the report “1. There were no contemporaneous documents that a Dieticians or Falls Team referral had been made by the Care Home personnel in question
” 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 Recommend that the provider source training for all staff on effective record keeping, dementia and nutrition.
Verbatim wording from the response “Training:
We visited the provider on 16 January 2020 and scrutinised the training programme at Barley Brook. Wigan Council recommended that the provider sources training for all staff in both effective record keeping and dementia and nutrition. Wigan Council consider that such training is necessary to ensure that all staff team members recognise the importance of good record keeping, their role within this and what the consequences of poor record keeping can be. The training in relation to dementia and nutrition will provide staff with a deeper understanding in order to deliver a more person-centred service. The training will provide learning such as how dementia can affect a person intake including managing weight loss, changes in food taste and preferences that can occur and methods in which to increase a person’s intake.” Source location 2019-0407-Response-by-Wigan-Council
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 Continue quality-assurance monitoring through support visits, scrutiny of records and care plans, and follow-up of referral effectiveness.
Verbatim wording from the response “Between the 11th July 2019 and 16th January 2020, a total of 9 monitoring and support visits have taken place at Barley Brook. This involves the Quality Performance Officers from Wigan Council visiting the service and scrutinising service delivery and making recommendations to ensure that the service is not only compliant with the Care Quality Commission’s regulations but that best practice and innovation is instilled into all areas.” Source location 2019-0407-Response-by-Wigan-Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the provider’s uptake of recommended training and its impact on service-user experiences.
Verbatim wording from the response “Training:
We visited the provider on 16 January 2020 and scrutinised the training programme at Barley Brook. Wigan Council recommended that the provider sources training for all staff in both effective record keeping and dementia and nutrition. Wigan Council consider that such training is necessary to ensure that all staff team members recognise the importance of good record keeping, their role within this and what the consequences of poor record keeping can be. The training in relation to dementia and nutrition will provide staff with a deeper understanding in order to deliver a more person-centred service. The training will provide learning such as how dementia can affect a person intake including managing weight loss, changes in food taste and preferences that can occur and methods in which to increase a person’s intake.” Source location 2019-0407-Response-by-Wigan-Council
Open published response
16 Aug 2017 Helen Theresa Cannon · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to ensure understanding of the meaning of countersigning risk assessment checklists View source Failure to seek medical or paramedic assistance when warranted by a person's condition View source Failure to address inaccuracies in moving and handling risk assessment checklists during investigations 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
Helen Theresa Cannon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.
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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the meaning of countersigning risk assessment checklists
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it . It was his belief that he signed the checklist simply to agree that he had been present .
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical or paramedic assistance when warranted by a person's condition
Wider context from the report “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain . It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon .
” 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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to address inaccuracies in moving and handling risk assessment checklists during investigations
Wider context from the report “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present.
” Open source report
6 Jul 2017 Cameron Chadwick · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to repair a carriageway pothole meeting the stated repair threshold View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Cameron Chadwick · 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
Cameron Chadwick was riding a motorcycle on Helvellyn Road, Wigan, on 7 February 2017 when he lost control, fell, and sustained injuries that led to his death. Evidence at the inquest concerned a pothole near the accident site, reportedly measured at 45mm deep, although the exactness of the measurement could not be fully guaranteed.
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 Wigan Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to repair a carriageway pothole meeting the stated repair threshold
Wider context from the report “1. During the Inquest evidence was heard that:-
i. Evidence was given at the Inquest that there was a pothole in the carriageway near to where the accident that caused Cameron Chadwick’s death occurred. An officer of Wigan Council informed the Court that a pothole that was 40mm or more deep should be repaired . A Police Officer gave evidence that whilst he could not fully guarantee the exactness of his measurement the pothole was 45mm deep at the time of this accident.
” 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 Repair the carriageway pothole through temporary and subsequent permanent repairs.
Verbatim wording from the response “However, in line with best practice and from the Regulation 28 - Coroner’s Report advising us this incident, the highway asset management service has exercised their discretion to carry out a repair, although it did not actually meet the Council’s highway intervention level for a safety defect. For recording purposes I can advise that a temporary repair to the carriageway pothole was actioned 6th July 2017. This temporary repair was followed up with a permanent one on 17th July 2017. I have attached a photograph referenced H2 as evidence of this repair.” Source location Response from Wigan Council
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 Regular inspections and repairs under the Highway Safety Inspection Policy address highway safety defects according to the existing danger-based intervention thresholds.
Verbatim wording from the response “I can confirm that Wigan Council has in place a Highway Safety Inspection Policy for its highway network. All highways are subject to regular safety inspections by competent highway inspectors. Any safety defects found during those inspections giving rise to a real source of dangers to reasonable users would have been subject to repair within certain timescales dependent on the degree of the danger.” Source location Response from Wigan Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The pothole was 36mm deep, not the 45mm depth reported in police evidence.
Verbatim wording from the response “I can confirm that a Technical Officer (Highways and Streetworks) and a Technical Design Officer (Highways) from the Highway Asset Management Team, who are experienced in carrying out highway safety inspections, attended the location of the incident at Hevvellyn Road, Norley Hall, Wigan on 6th July 2017. The purpose of this site visit was to establish the depth of the carriageway pothole. In the police report (exhibit DJH 2- point 19) the police officer gave evidence that the pothole was 4.5cm (45mm) deep at its lowest point at the time of the accident.” Source location Response from Wigan Council
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations