PFD report

Jordan Shaun Mhlanga-Veira · Prevention of Future Deaths report

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Issued 26 Nov 2021•Berkshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised2

  1. Failure to apply a comparable safety approach to non-tidal waters
  2. Failure to ensure adequate safety measures at the site
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Commence a signage pilot at Cock Marsh testing locations, wording and effectiveness of warnings about depth, strong currents and hidden obstacles.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated plannedThe respondent said that this action was planned when they made their response on 29 November 2021.
  2. Action

    Complete a site visit and full review of the Cock Marsh visitor risk assessment.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
  3. Action

    Create a distinct visitor risk assessment for the beach and similar Cock Marsh locations, specifically addressing drowning risk and non-obvious hazards.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated plannedThe respondent said that this action was planned when they made their response on 29 November 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9

  1. Position

    Landowners are not required to safeguard obvious risks voluntarily undertaken by visitors, including entering the water.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to apply a comparable safety approach to non-tidal waters

Wider context from the report

“2. Consideration should be given to approaching safety in relation to non-tidal waters in the same or similar way that tidal waters are dealt with. Whilst some proportionality will of course be required, it may be that there is some predictability to areas of particular danger in inland waters, for instance where these are regularly used by members of the public (as was the case here), and with reference to weather, and bank holidays. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure adequate safety measures at the site

Wider context from the report

“1. Whilst it is not a matter for the coroner at an inquest to recommend particular safety measures, I ask that safety measures at the site be reviewed urgently, to include consideration of warning signs, position of throw ropes, and consideration of buoys in the water (at the point where it becomes deep). I appreciate that many of these measures will contain both advantages and disadvantages, and this will be a matter for debate amongst the appropriate agencies referred to in this report. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Commence a signage pilot at Cock Marsh testing locations, wording and effectiveness of warnings about depth, strong currents and hidden obstacles.

Verbatim wording from the response

“iii) A signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures at the specific location warning of depth, strong currents, and hidden obstacles. The risk assessment will also consider the location of existing lifesaving equipment and whether further provision should be made.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete a site visit and full review of the Cock Marsh visitor risk assessment.

Verbatim wording from the response

“28. Following your report, it was agreed as a priority the General Manager ████████, Lead Ranger, ████████ and Head of Compliance ████████ would visit the site and review the current risk assessment and consider whether further reasonably practicable and effective measures could be put in place to reduce the risk associated voluntarily accepted by those who chose to swim in that area of the Thames.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

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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 a distinct visitor risk assessment for the beach and similar Cock Marsh locations, specifically addressing drowning risk and non-obvious hazards.

Verbatim wording from the response

“i) Following the site visit and review of the current visitor risk assessment, which covers a large area of land and a number of other visitor risks, the area known as the beach and other potential similar locations at Cock Marsh will be separately drawn out into a distinct visitor risk assessment specially to consider drowning risk.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

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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

Assess the location of existing lifesaving equipment and consider whether further provision is needed.

Verbatim wording from the response

“iii) A signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures at the specific location warning of depth, strong currents, and hidden obstacles. The risk assessment will also consider the location of existing lifesaving equipment and whether further provision should be made.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

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

Conduct public-safety risk assessments for owned or occupied assets, considering use, weather, bank holidays and water characteristics, and take empowered reasonably practicable risk-reduction steps.

Verbatim wording from the response

“4. Where the Environment Agency owns or occupies a site and it therefore forms part of our undertaking, we are under a duty to assess the risks our assets and landholdings pose. We do this by carrying out a public safety risk assessment which identifies measures to take to reduce risk to its staff and to the public. The risk assessment will address factors such as popularity of use and the factors which influence that popularity, such as weather and bank holidays. It will also take into account factors that may be influenced by the tidal or non-tidal nature of the water body. Taking all relevant factors into account, we then take all steps that are reasonably practicable and that we are empowered to take, to reduce and control those identified risks.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 5 · response
Published 29 November 2021

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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

Support and follow National Water Safety Forum guidance on managing safety at inland water sites.

Verbatim wording from the response

“Prevention of Accidents (‘RoSPA’) and supported by the Royal Life Saving Society UK (‘RLSS UK’). We support and follow its published guidance, ‘Managing Safety in Inland Water Sites’ https://www.flipsnack.com/rospacatalogue/rospa-managing-safety-at-inland-waters.html , guidance which was drawn to the attention of the Coroner, by ████████, during Jordan’s inquest. The guidance provides valuable advice for those in control of sites where members of the public have access to water.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 4 · response
Published 29 November 2021

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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

Regularly inspect owned or occupied assets and review public-safety risk assessments at suitable intervals to maintain appropriate risk controls.

Verbatim wording from the response

“Reasonable steps might include, for example, putting up warning signs on a weir to warn against or inform of the risks to swimming or canoeing. We continue to inspect regularly those assets to ensure the provided risk control”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 5 · response
Published 29 November 2021

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

Landowners are not required to safeguard obvious risks voluntarily undertaken by visitors, including entering the water.

Verbatim wording from the response

“12. The relevant statutory and common law provisions apply equally to coastal and inland waterways. The applicable law for landowners can be found within the Occupiers’ Liability Acts and for employers, the Health and Safety at Work etc. Act 1974. Neither of the statutes impose a duty on the landowner to guard against an obvious hazard such as a water course or provide risk mitigation measures for those who choose to undertake activity not being promoted or organised by the landowner or employer’s undertaking. The application of these statutory provisions and of the common law has been clearly and authoritatively stated by the High Court, Court of Appeal and the House of Lords.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 2 · response
Published 29 November 2021

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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

The same legal duties and water-safety approach apply to tidal and non-tidal waters, so no specific distinction is made between them.

Verbatim wording from the response

“31. The Trust has carefully considered the second matter of concern within the Regulation 28 report. For the reasons set out above the Trust does not believe there is any legal distinction between non-tidal and tidal waters or coastal or inland waterways. As such, the same legal duties apply to both coastal waters and inland waterways and tidal and non-tidal waters. The Trust does not make any specific distinction between coastal waters and inland waterways as far as water safety is concerned and undertakes risk assessments with annual reviews that consider visitor safety on the land it owns along the coastline and next to inland waterways. In both cases it applies the VSG guidance.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

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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

The Trust cannot unilaterally place buoys because it does not own, operate or control the River Thames.

Verbatim wording from the response

“24. Buoys. The Trust does not own, operate or control the River. It is not within its power to unilaterally place buoys in the water. However, even if it was, the Trust would have a very serious concern that the presence of buoys would indicate by implication that areas of the River were safe to swim in and thereby encourage people into the water. That would be contrary to the Trust’s overall approach to water safety and the relevant guidance. Further, buoys would, as the Trust understands it, interfere with the legitimate rights of users of the river. The Trust understands this is also the position of the Environment Agency.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 4 · response
Published 29 November 2021

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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

Public throw ropes are not generally provided because experience indicates they are vulnerable to theft and vandalism and may encourage misuse or perceived safety.

Verbatim wording from the response

“25. The position of throw ropes. The Trust does not generally provide throw ropes. It does not believe the specific rope referred to was located on National Trust land. Experience tells us that equipment such as throw ropes is often stolen and/or vandalised. The Trust’s experience is that the provision of public rescue equipment creates an inducement for either misuse or a perception of safety.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 4 · response
Published 29 November 2021

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

Established legislation and case law concerning public safety apply to both tidal and non-tidal waters; no statutory framework is absent.

Verbatim wording from the response

“1. We note the Coroner’s comment that there is ‘currently no statutory framework around safety measures applied to inland waters’ and we do not feel that this is the case. There is established legislation and case law concerning public safety, which applies to all waters, both tidal and non-tidal.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 5 · response
Published 29 November 2021

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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

Central government, including the Cabinet Office and Defra, is responsible for policy decisions on inland and coastal water safety.

Verbatim wording from the response

“7. We note the Coroner’s comment that further consideration should be given to developing water safety. Policy decisions on the matter of inland and coastal water safety are the responsibility of central government, including the Cabinet Office and the Department for Environment, Food and Rural Affairs.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 6 · response
Published 29 November 2021

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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

The Environment Agency has very limited capacity to introduce safety measures for swimmers entering the water at Cockmarsh Field.

Verbatim wording from the response

“5. Under Byelaw 63(b) it is an offence to bathe in the Thames where the Environment Agency has put up a sign forbidding it. However, our powers to erect a sign in our capacity as navigation authority are limited to circumstances connected to navigation itself, not recreation. For example, under Byelaw 63(b), we could erect a sign to prohibit swimming in order to prevent interference with the public right to navigate the Thames, but not to prohibit swimming generally.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 2 · response
Published 29 November 2021

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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

The National Trust, as landowner controlling access, has responsibility for site safety measures such as warning signs and rescue devices.

Verbatim wording from the response

“1. Our response has been prepared following discussions with the National Trust. The National Trust is the landowner at Cockmarsh Field, Cookham and”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 1 · response
Published 29 November 2021

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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

The site is not owned or occupied by the Environment Agency, whose role there is limited to navigation authority functions.

Verbatim wording from the response

“2. The Environment Agency is responsible for safety on waterside assets it owns, operates or occupies (such as locks, weirs and bridges). In the case of Cockmarsh Field, the scope of our role is as navigation authority for the stretch of river. We do not own or occupy the land and have no assets positioned there.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 5 · response
Published 29 November 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Contribute to the National Water Safety Forum consultation on improving water safety.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
  2. 2

    Participate actively in the HSE-approved Visitor Safety Group on public safety.

    Stated by Environment AgencyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
  3. 3

    Continue working with the National Trust, within navigation-authority powers and duties, to improve public safety at the Thames.

    Stated by Environment AgencyStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
  4. 4

    Publish public water-safety advice and run awareness campaigns, including partnership patrols at popular waterway locations.

    Stated by Environment AgencyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Environment Agency has specific powers and duties concerning the River Thames and navigation at this location.

    Stated by The National Trust For Places Of Historic Interest Or Natural BeautyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Contribute to the National Water Safety Forum consultation on improving water safety.

Verbatim wording from the response

“32. It remains the view of the Trust that the best control mechanism for the risks associated with Coastal and Inland Waterways and tidal and non-tidal water courses is better education. The Trust recently contributed the National Water Safety Forum consultation on improving water safety and noted with interest at the recent conference the planned adoption of new water safety messaging and campaigns for 2022.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 5 · response
Published 29 November 2021

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

Participate actively in the HSE-approved Visitor Safety Group on public safety.

Verbatim wording from the response

“13. The Environment Agency is also an active member of the HSE approved Visitor Safety Group https://www.visitorsafety.group/, which also works in this area of public safety. Other members of the group include the National Trust and British Waterways.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 4 · response
Published 29 November 2021

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 working with the National Trust, within navigation-authority powers and duties, to improve public safety at the Thames.

Verbatim wording from the response

“14. The Environment Agency will continue to work with the National Trust so far as our powers and duties as a navigation authority allow, to ensure the safety of the public visiting the Thames.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 4 · response
Published 29 November 2021

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

Publish public water-safety advice and run awareness campaigns, including partnership patrols at popular waterway locations.

Verbatim wording from the response

“12. We publish advice for the public on how to stay safe while visiting waterways: www.gov.uk/government/publications/staying-safe-around-water . We run information campaigns to raise awareness of water safety around our assets and landholdings. We focus our attention on those assets which are known to be popular swimming or canoeing spots, for example, Teddington Lock. For example, in June 2021, in partnership with local representatives of other agencies with water safety roles and responsibilities on the river Thames – Royal Berkshire Fire and Rescue Service, Thames Valley Police, Royal Borough of Windsor and Maidenhead Council – we carried out a patrol in the Boulters Lock and Ray Mill island areas of Maidenhead, engaging with members of the public about the risks posed by swimming in the Thames and other waterbodies.”

Source location

2021-0403-Response-from-Enviroment-Agency_Published
Page 4 · response
Published 29 November 2021

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 Environment Agency has specific powers and duties concerning the River Thames and navigation at this location.

Verbatim wording from the response

“10. A landowner of one side of the bank of the river, may have riparian ownership of the riverbed to the middle of the watercourse where generally the ownership would transfer to the opposing bank landowner a full review of title deeds of any landowners would be needed in order to ascertain the riverbed ownership at any particular point. The Trust understands the Environment Agency is the authority with specific powers and duties in relation to the River Thames and navigation at this location.”

Source location

2021-0403-Response-from-National-Trust_Published
Page 2 · response
Published 29 November 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026