Concerns raised 3 Lack of safety warnings about unseen cold-water and water-flow hazards View source Unavailability of water-rescue aids at incident scenes View source Lack of ready access to places of safety and support for casualties 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
MOHAMMED BILAL ZEB · 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
MOHAMMED BILAL ZEB, aged 18, drowned after jumping into the River Wharfe at Linton Falls on 31 July 2020; he could not swim and became unresponsive. Concerns included the absence of flotation or rescue aids, difficult access and conditions for rescuers, and a lack of apparent safety warnings about hazards including cold water, water flow and underwater obstructions.
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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of safety warnings about unseen cold-water and water-flow hazards
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident.
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties.
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards . Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of water-rescue aids at incident scenes
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident .
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties.
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels.
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to places of safety and support for casualties
Wider context from the report “(1) Recognising the Deceased’s inability to swim and that he was soon unresponsive, there were nevertheless no aids eg flotation aid, throw line or water rescue reach pole to help the rescuers, or the deceased himself if he had been responsive, accessible at the scene of the incident.
(2) Police Officers and paramedics courageously had to swim and put themselves at risk to try and reach the casualty and support the deceased’s body while CPR was attempted in less than helpful positions and conditions for recovery of an inert casualty. Recognising that the Falls are a popular open, natural attraction, valued for its natural features, nevertheless the steep banks and rocks permit no ready access to places of safety and support for casualties .
It was not until a team from Upper Wharfedale Fell Rescue attended that he was able to be moved to a more suitable location.
(3) No one present appeared to have been aware of any safety warnings either at the location or by other media about risks to life from cold water, current/ speed of water flow, underwater obstructions and obstacles, all ‘unseen’ hazards. Further that such risks do not disappear - instead vary, remaining hazardous - in summer months even after drop in water levels.
” Open source report
Concerns raised 9 Failure to adjust the relevant safety assessment after serious injury information View source Insufficient collation and sharing of potentially important incident information View source Deficient national guidelines for incident information collation and sharing View source Failure to accurately collect, share and categorise incident information View source Failure to inform the relevant road-management function of a serious incident View source Failure of location risk assessment to recognise risk and prioritise major works funding View source Failure to maintain tree trimming sufficient to preserve road lighting View source Failure to require sharing of damage-only incidents View source Failure to properly identify incident locations in shared information View source See 6 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
Mr Sean Craig Salvin · 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
Sean Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing risk.
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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adjust the relevant safety assessment after serious injury information
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made . Amey advised the court that they had not been made aware of this incident.
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient collation and sharing of potentially important incident information
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents . If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient.
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Deficient national guidelines for incident information collation and sharing
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents. If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately collect, share and categorise incident information
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared. It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant road-management function of a serious incident
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made. Amey advised the court that they had not been made aware of this incident .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of location risk assessment to recognise risk and prioritise major works funding
Wider context from the report “e) The risk assessment of this location was also of concern to the inquest, both in respect of prioritisation of funding for major work and in terms of the recognition of the degree of risk . This was a location where traffic might be expected to be travelling comparatively quickly with the low hazard of trees immediately adjoining the carriageway. The emergence of a propensity to flood was a most important addition to the risk calculation .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain tree trimming sufficient to preserve road lighting
Wider context from the report “g) Witnesses reported the street lighting as ‘adequate’ and a site inspection did not suggest otherwise. However, the growth of trees and the development of leaves in Spring and Summer will inevitably reduce the lighting available on the road unless proper (and probably substantial) trimming takes place . The court was told that this is a recognised and regular maintenance issue but a concern would arise if this was reduced for any reason such as future budgetary constraints .
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to require sharing of damage-only incidents
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared . It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation.
” 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 Yorkshire Water Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to properly identify incident locations in shared information
Wider context from the report “b) In particular, such sharing of information as there was did not always fully or even properly identify the location concerned . The inquest showed that it was not difficult to identify that a number of incidents had occurred in the same place prior to the fatal collision.
” Open source report