PFD report

James Francis PARSONS · Prevention of Future Deaths report

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Issued 22 Feb 2023•Cornwall and Isles of Scilly

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.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
6

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

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

Report evidence summary

Concerns raised6

  1. Failure to close the pier to public access when unsafe conditions are present
    Part of recurring concern: Failure to prevent public access to closed or restricted hazardous sites
  2. Harbour currents making swimming to safety difficult
    Part of recurring concern: Uncontrolled dangerous currents affecting swimmers
  3. Lack of access ladders or a refuge area for people in the water
    Part of recurring concern: Inadequate controls for drowning risks at open-water locations
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.1

  1. Action

    Consider the event organiser’s response before permitting the event to proceed, ensuring reasonable precautions are in place.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    The Health and Safety Executive is responsible for statutory enforcement concerning safety at the harbour’s dock premises.

    Stated by Cornwall CouncilRedirects 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 close the pier to public access when unsafe conditions are present

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

Is this part of a recurring concern?

Yes — Failure to prevent public access to closed or restricted hazardous sites.

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

Harbour currents making swimming to safety difficult

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

Is this part of a recurring concern?

Yes — Uncontrolled dangerous currents affecting swimmers.

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

Lack of access ladders or a refuge area for people in the water

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

Is this part of a recurring concern?

Yes — Inadequate controls for drowning risks at open-water locations.

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

Lack of railing protection alongside harbour and pier sheer drops

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing falls from water-adjacent public routes; Inadequate physical barriers preventing access to dangerous drops or areas.

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

Inadequate lighting on the pier

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

Is this part of a recurring concern?

Yes — Inadequate outdoor safety lighting.

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

Unaddressed trip hazards around the harbour wall

Wider context from the report

“There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival. ”

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

Consider the event organiser’s response before permitting the event to proceed, ensuring reasonable precautions are in place.

Verbatim wording from the response

“The SAG are awaiting a response from the event organiser in relation to what additional measures are planned for this year following the tragic death, including safety measures for the harbour area and the sale of alcohol. The response will be supported by attendance at a SAG, so that all agencies have an opportunity to speak directly with the event organiser. The response will be considered by the members of the SAG prior to the event going ahead to ensure that reasonable precautions are in place.”

Source location

Response from Cornwall Council
Page 2 · response
Published 28 February 2023

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 Health and Safety Executive is responsible for statutory enforcement concerning safety at the harbour’s dock premises.

Verbatim wording from the response

“In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.”

Source location

Response from Cornwall Council
Page 2 · response
Published 28 February 2023

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

Statutory health and safety enforcement for dock premises falls outside the council’s powers under the Health and Safety at Work etc. Act 1974.

Verbatim wording from the response

“In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.”

Source location

Response from Cornwall Council
Page 2 · response
Published 28 February 2023

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

Existing railings, signage and lifebuoy aids are considered sufficient to address harbour safety risks.

Verbatim wording from the response

“Over the years, the Harbour & Dock Company has given the utmost priority to safety aspects of the Harbour and continues to do so each year. We are satisfied with the measures we have in place which include railings, signage and lifebuoy aids. Being a popular holiday destination, Porthleven attracts thousands of visitors each year without incident which clearly demonstrates the Harbour is a safe environment.”

Source location

Response from Porthleven Harbour Dock Company
Page 3 · response
Published 28 February 2023

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 Festival is responsible for health and safety matters during festival events, working with Cornwall Council’s Health and Safety team.

Verbatim wording from the response

“We work very closely with the Porthleven Food Festival and have done since the Festival’s inauguration 15 years ago. Each year, Porthleven Harbour & Dock Company grants a right for the Festival to use the Harbour Head, the Shipyard and other areas within the Inner Harbour over the 2-3 days of the festival. This is granted on the basis that the Festival take responsibility for all health and safety matters, and to that end, they work closely with Cornwall Council Health & Safety team to put these measures in place. In the 15 years since the Festival was established, we are not aware of any major incidents or injuries and certainly no persons entering the water even though alcohol is a feature of the Festival.”

Source location

Response from Porthleven Harbour Dock Company
Page 2 · response
Published 28 February 2023

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

Cornwall Council’s Environmental Health and licensing offices are responsible for enforcing temporary measures for festival-related increased risks.

Verbatim wording from the response

“For festivals and other events where paid work exists, there is a work activity and the Health and Safety at Work etc. Act 1974 applies. HSE has no vires in relation to festivals, other public events or to the bars/cafes with seating near to the harbour edge. The vires falls to the Local Authority, in this case the licensing arm of Cornwall Council and their Environmental Health Office (EHO). It is appreciated that such events may increase the health and safety risks, in particular the risk of falls, at the harbour and pier. It will be for the event organiser and Porthleven Harbour & Dock Company to convince the EHO and the licensing office, that have taken sufficient action to address the increased risk of a fall to danger occurring during the festival due to an influx of people, alcohol and low lighting converging near to or having access to open edges.”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 28 February 2023

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

HSE has no regulatory powers over harbour areas without work activity or risks increased by festivals and other public events.

Verbatim wording from the response

“Porthleven Harbour is mainly concerned with recreational activities, including the mooring of privately owned pleasure boats. The Health and Safety at Work etc. Act 1974 only applies to Porthleven Harbour at locations where a work activity is taking place. That is paid work or where there is some form of remuneration, there is an employer/employee or self-employed person. Where the Act does not apply, HSE has no vires or regulatory powers.”

Source location

Response from Health and Safety Executive
Page 1 · response
Published 28 February 2023

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

Event organisers and Porthleven Harbour & Dock Company are responsible for temporary measures addressing increased festival risks at the pier.

Verbatim wording from the response

“The organisers may need to put in place temporary control measures in order to address the increased risk in particular areas. If there is a temporary increased risk at the pier area, it would be for the Event Organiser and Porthleven Harbour & Dock Company to take action to address it. As it does not relate to the crabbing operation but to the festival, enforcement of temporary measures would fall to the EHO and licensing office for enforcement.”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 28 February 2023

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.5

  1. 1

    Attend a Safety Advisory Group meeting to discuss the event organiser’s additional harbour and alcohol-safety measures.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.
  2. 2

    Write to harbours and event organisers about the incident and ask them to include harbour edges in event risk assessments.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.
  3. 3

    Continue reviewing harbour health and safety issues in consultation with appropriate consultants and advisers.

    Stated by Porthleven Harbour & Dock CompanyStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
  4. 4

    Continue working with the Porthleven Food Festival and other groups using the harbour for publicly attended events.

    Stated by Porthleven Harbour & Dock CompanyStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
  5. 5

    Visit the commercial crabbing area with the dutyholder to review its health and safety arrangements.

    Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.

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

  1. 1

    There is no evidence that the deceased fell into the water at the harbour or that the Harbour Company failed to recognise public danger.

    Stated by Porthleven Harbour & Dock CompanyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Attend a Safety Advisory Group meeting to discuss the event organiser’s additional harbour and alcohol-safety measures.

Verbatim wording from the response

“The SAG are awaiting a response from the event organiser in relation to what additional measures are planned for this year following the tragic death, including safety measures for the harbour area and the sale of alcohol. The response will be supported by attendance at a SAG, so that all agencies have an opportunity to speak directly with the event organiser. The response will be considered by the members of the SAG prior to the event going ahead to ensure that reasonable precautions are in place.”

Source location

Response from Cornwall Council
Page 2 · response
Published 28 February 2023

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 harbours and event organisers about the incident and ask them to include harbour edges in event risk assessments.

Verbatim wording from the response

“Thinking more widely than Porthleven, Cornwall Council will write to all harbours and event organisers for events near harbours, making them aware of this tragic incident and asking them to consider harbour edges as part of their risk assessment process. This will be completed by the end of April 2023.”

Source location

Response from Cornwall Council
Page 2 · response
Published 28 February 2023

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 reviewing harbour health and safety issues in consultation with appropriate consultants and advisers.

Verbatim wording from the response

“We are committed to ongoing reviews of health and safety issues and will continue to do so in consultation with appropriate consultants and advisors. Any suggestions on further improvements to health & safety issues will of course be considered very carefully. We will continue to work closely with the Porthleven Food Festival and other groups that might use the Harbour for publicly attended events in the future.”

Source location

Response from Porthleven Harbour Dock Company
Page 3 · response
Published 28 February 2023

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 Porthleven Food Festival and other groups using the harbour for publicly attended events.

Verbatim wording from the response

“We are committed to ongoing reviews of health and safety issues and will continue to do so in consultation with appropriate consultants and advisors. Any suggestions on further improvements to health & safety issues will of course be considered very carefully. We will continue to work closely with the Porthleven Food Festival and other groups that might use the Harbour for publicly attended events in the future.”

Source location

Response from Porthleven Harbour Dock Company
Page 3 · response
Published 28 February 2023

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

Visit the commercial crabbing area with the dutyholder to review its health and safety arrangements.

Verbatim wording from the response

“We will visit to review the health and safety arrangements at the commercial crabbing area with the Dutyholder, however an initial observation is that the Dutyholder appears in compliance with the Health & Safety at Work etc. Act 1974 at this area.”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 28 February 2023

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

There is no evidence that the deceased fell into the water at the harbour or that the Harbour Company failed to recognise public danger.

Verbatim wording from the response

“Having read your report, it would seem there is no evidence of where the deceased fell into the water or that he fell at all. There are many areas beyond the Harbour where it is just as possible that Mr Parsons may have entered the water from the rocks in the Outer or Inner Harbour or from Porthleven beach or indeed other areas close to Porthleven.”

Source location

Response from Porthleven Harbour Dock Company
Page 3 · response
Published 28 February 2023

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