PFD report

Dwayne Daniel Ryan Thompson · Prevention of Future Deaths report

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Issued 15 Feb 2019•Manchester South

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
1

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to maintain effective physical access controls at reservoirs
  2. Failure to design reservoir risk signage for people with learning disabilities
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Responsibility for managing risks to members of the public rests legally with the reservoir duty holder.

    Stated by The Royal Society For The Prevention Of AccidentsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 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. ”

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 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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
Page 2 · response
Published 6 June 2019

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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
Page 1 · response
Published 6 June 2019

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 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
Page 1 · response
Published 6 June 2019

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.6

  1. 1

    Contact local authorities and known key duty holders, including reservoir companies, to disseminate the updated inland-waters safety guidance.

    Stated by The Royal Society For The Prevention Of AccidentsStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  2. 2

    Update national guidance on managing safety at inland waters, including risk communication and hazard identification.

    Stated by The Royal Society For The Prevention Of AccidentsStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  3. 3

    Invite all Greater Manchester local authorities to a workshop considering the Manchester City Centre drowning review findings and wider community water-safety issues.

    Stated by The Royal Society For The Prevention Of AccidentsStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  4. 4

    Complete the commissioned analysis of trauma data to improve understanding of autism as a drowning risk factor.

    Stated by The Royal Society For The Prevention Of AccidentsStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2019.
  5. 5

    Publish the analysis of trauma data on autism as a drowning risk factor.

    Stated by The Royal Society For The Prevention Of AccidentsStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  6. 6

    Support fire services and partners to develop and formalise a national education pack on autism for water-safety and general-safety practitioners.

    Stated by The Royal Society For The Prevention Of AccidentsStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.

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

Contact local authorities and known key duty holders, including reservoir companies, to disseminate the updated inland-waters safety guidance.

Verbatim wording from the response

“Action 1. We have recently updated our national guidance: Managing Safety at Inland Waters (2). This is our principal advice for duty holders, and it includes examples and approaches such as risk communication and identification of hazards. The latest edition was published December 2018, and it is our intention to contact all Local Authorities and known key duty holders including reservoir companies to inform them of the updated advice before the end of 2019.”

Source location

2019-0055-Response-by-RoSPA
Page 2 · response
Published 6 June 2019

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

Update national guidance on managing safety at inland waters, including risk communication and hazard identification.

Verbatim wording from the response

“Action 1. We have recently updated our national guidance: Managing Safety at Inland Waters (2). This is our principal advice for duty holders, and it includes examples and approaches such as risk communication and identification of hazards. The latest edition was published December 2018, and it is our intention to contact all Local Authorities and known key duty holders including reservoir companies to inform them of the updated advice before the end of 2019.”

Source location

2019-0055-Response-by-RoSPA
Page 2 · response
Published 6 June 2019

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

Invite all Greater Manchester local authorities to a workshop considering the Manchester City Centre drowning review findings and wider community water-safety issues.

Verbatim wording from the response

“Action 5. It is our intention to invite all Greater Manchester Local Authorities to a workshop to consider the findings from the City Centre review and the above points.”

Source location

2019-0055-Response-by-RoSPA
Page 3 · response
Published 6 June 2019

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 the commissioned analysis of trauma data to improve understanding of autism as a drowning risk factor.

Verbatim wording from the response

“Action 3. The impact of autism on non-fatal drownings is not known in the UK. We have commissioned an analysis of trauma data to better evidence a collective understanding of autism as a risk factor. This is expected to be ready for publication before the end of 2019.”

Source location

2019-0055-Response-by-RoSPA
Page 3 · response
Published 6 June 2019

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 the analysis of trauma data on autism as a drowning risk factor.

Verbatim wording from the response

“Action 3. The impact of autism on non-fatal drownings is not known in the UK. We have commissioned an analysis of trauma data to better evidence a collective understanding of autism as a risk factor. This is expected to be ready for publication before the end of 2019.”

Source location

2019-0055-Response-by-RoSPA
Page 3 · response
Published 6 June 2019

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

Support fire services and partners to develop and formalise a national education pack on autism for water-safety and general-safety practitioners.

Verbatim wording from the response

“Action 4. We will support the fire services’ and partners’ efforts to develop and formalise a national education pack to help the water safety or general safety practitioner to understand autism better. At the time of drafting this response I am not in receipt of an agreed publication date, but will confirm in writing by the end of July 2019.”

Source location

2019-0055-Response-by-RoSPA
Page 3 · response
Published 6 June 2019

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

Data last updated 7 September 2026