PFD report

DAVID CHIAKA EJIMOFOR · Prevention of Future Deaths report

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Issued 4 Jun 2025•Swansea and Neath Port Talbot

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
12

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 raised3

  1. Lack of evidence that other breakwater deterrence measures are effective
    Part of recurring concern: Failure to verify compliance and effectiveness of implemented safety changes
  2. Dangerous jumping from and water around the breakwater
  3. Lack of lifeguard cover at the breakwater during higher-risk spring and summer periods
    Part of recurring concern: Unreliable lifeguard provision for aquatic safety
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.6

  1. Action

    Assess whether additional deterrent measures are necessary after monitoring analysis, in cooperation with RNLI and ABP.

    Stated by Neath Port Talbot County Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  2. Action

    Review the beach safety assessment and decide lifeguard deployment for the 2026 summer season using monitoring findings.

    Stated by Neath Port Talbot County Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  3. Action

    Prepare a post-season report containing recommendations based on the monitoring findings.

    Stated by Royal National Lifeboat InstitutionStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    The council cannot police access to the breakwater because it is third-party-owned land outside the council’s ownership or control.

    Stated by Neath Port Talbot County Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.

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 evidence that other breakwater deterrence measures are effective

Wider context from the report

“(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it. (2) Jumping from, and the water around, the breakwater is known to be dangerous. (3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk. (4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today. (5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk. ”

Is this part of a recurring concern?

Yes — Failure to verify compliance and effectiveness of implemented safety changes.

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

Dangerous jumping from and water around the breakwater

Wider context from the report

“(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it. (2) Jumping from, and the water around, the breakwater is known to be dangerous. (3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk. (4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today. (5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk. ”

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

Lack of lifeguard cover at the breakwater during higher-risk spring and summer periods

Wider context from the report

“(1) There are no lifeguards stationed at the breakwater during higher risk periods in the spring and summer months (when the weather is good and the tides high), when children and young people have been seen/known to jump into the water from it. (2) Jumping from, and the water around, the breakwater is known to be dangerous. (3) The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months (when the weather is good and the tides high) had been in place historically and was known to be effective at reducing the risk. (4) I was not given, in evidence, a satisfactory or cogent explanation as to why that measure had been removed prior to DAVID’s death, nor why that measure continues to be absent today. (5) Nor was I shown any evidence that other deterrence measures put in place since DAVID’s death (including clearer signage and a limited-height barrier) are otherwise working effectively to reduce the risk. ”

Is this part of a recurring concern?

Yes — Unreliable lifeguard provision for aquatic safety.

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

Assess whether additional deterrent measures are necessary after monitoring analysis, in cooperation with RNLI and ABP.

Verbatim wording from the response

“Monitoring of the breakwater is ongoing. Once the analysis is complete, NPTCBC, in cooperation with RNLI and ABP, will be able to assess whether any additional deterrent measures are necessary to effectively reduce the identified level of risk still further.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 5 · response
Published 11 June 2025

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

Review the beach safety assessment and decide lifeguard deployment for the 2026 summer season using monitoring findings.

Verbatim wording from the response

“As noted above, the RNLI is currently undertaking an exercise to monitor activity in the vicinity of the breakwater. These monitoring efforts and discussions are expected to continue across the summer 2025, to help inform a formal review of the Beach safety assessment and in turn a decision regarding lifeguard deployment for the 2026 summer season. Should it ultimately be determined that additional lifeguard coverage is necessary, NPTCBC’s intention would be to implement this provision during 2026 subject to the necessary funding being available.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 3 · response
Published 11 June 2025

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

Prepare a post-season report containing recommendations based on the monitoring findings.

Verbatim wording from the response

“The purpose of the daily monitoring is to understand how many people are using Little Beach and, importantly, how many people are entering the water from the breakwater. This will allow the RNLI to make recommendations to its partner, Neath Port Talbot Council.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 1 · response
Published 11 June 2025

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 daily use of Aberavon beach, Little Beach and the breakwater throughout the 2025 lifeguarding season.

Verbatim wording from the response

“1. Undertaking daily monitoring of people using:”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 1 · response
Published 11 June 2025

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 and complete a signage, fencing and barrier review, including risk assessment of deterrence options.

Verbatim wording from the response

“We will seek to respond to the point of deterrence measures (including signage and a limited height barrier) that has been raised by the Coroner's concerns and to identify any changes to signage, barriers and/or fencing at the breakwater to mitigate the risk of any future death by undertaking a signage, fencing and barrier review and implementing any necessary actions identified by such review. The review has commenced and will risk assess each option to ensure that by reducing one risk it does not create another. The initial review is anticipated to be concluded by the end of”

Source location

Response from ASSOCIATED BRITISH PORTS
Page 1 · response
Published 11 June 2025

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

Repeat and disseminate a water-danger awareness communication through media including Instagram.

Verbatim wording from the response

“Associated British Ports are repeating this summer an awareness communication that has been run in previous summers warning of the dangers of water. The communication is posted on various media to include Instagram.”

Source location

Response from ASSOCIATED BRITISH PORTS
Page 2 · response
Published 11 June 2025

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 council cannot police access to the breakwater because it is third-party-owned land outside the council’s ownership or control.

Verbatim wording from the response

“NPTCBC cannot police access to the breakwater, whether by lifeguard provision or otherwise. The breakwater is outside NPTCBC’s ownership.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 2 · response
Published 11 June 2025

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 breakwater risk has worsened, and the deceased accessed it outside historical lifeguard operating hours.

Verbatim wording from the response

“The practice of placing a lifeguard at the breakwater at times of higher risk in the spring and summer months had been in place historically and was known to be effective at reducing the risk.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 3 · response
Published 11 June 2025

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

If RNLI’s current assessment recommends no changes, existing beachfront lifeguarding provision will continue under those recommendations.

Verbatim wording from the response

“The current Beach safety assessments continue to recommend services along the Aberavon beach front area encouraging and instructing the public to swim at lifeguarded areas and during lifeguarded times. NPTCBC awaits the outcome of RNLI’s current monitoring and risk assessment period following which, if recommended, changes in service along the beachfront area will be implemented. If there are no changes implemented NPTCBC will continue to provide the lifeguarding provision in line with the current RNLI recommendations.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 4 · response
Published 11 June 2025

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

Any additional lifeguard coverage depends on necessary funding being available.

Verbatim wording from the response

“As noted above, the RNLI is currently undertaking an exercise to monitor activity in the vicinity of the breakwater. These monitoring efforts and discussions are expected to continue across the summer 2025, to help inform a formal review of the Beach safety assessment and in turn a decision regarding lifeguard deployment for the 2026 summer season. Should it ultimately be determined that additional lifeguard coverage is necessary, NPTCBC’s intention would be to implement this provision during 2026 subject to the necessary funding being available.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 3 · response
Published 11 June 2025

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

Lifeguarding provision on the breakwater is addressed through RNLI recommendations and ABP’s engagement as landowner.

Verbatim wording from the response

“NPTCBC will continue its dialogue with RNLI in particular but also with ABP. NPTCBC will be led by RNLI’s recommendations in view of their nationally recognised expertise and will continue to address recommendations as far as is practicable within resource and budgetary constraints. ABP’s engagement with RNLI as to provision of services on the breakwater itself is beyond NPTCBC’s knowledge.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 2 · response
Published 11 June 2025

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

Preventing access to water should be undertaken by security guards or wardens rather than lifeguards deployed to facilitate bathing.

Verbatim wording from the response

“Lifeguards are normally deployed to facilitate bathing rather than preventing aquatic activities. If solely deployed to stop access it would be more appropriate to deploy a security guard or warden service.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 3 · response
Published 11 June 2025

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

Lifeguarding cannot be provided without the landowner’s request or consent, and the RNLI has no contract with the breakwater owner.

Verbatim wording from the response

“As set out at the inquest, although the RNLI chooses to provide lifeguarding services, it has no legal duty to do so. Importantly, it cannot provide any service without the landowners or the occupier’s request or consent. It is entirely a matter for the landowner or occupier whether they ask and contract with the RNLI to provide a lifeguarding service.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 1 · response
Published 11 June 2025

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

Universal signage and access restrictions are impracticable; fencing is cost-prohibitive and may be circumvented by people entering the water around it.

Verbatim wording from the response

“Restricting access or even universal provision of signage at all possible sites would be almost impossible and, in many locations, would prove to be highly unpopular.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 3 · response
Published 11 June 2025

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

    Continue collaborating with RNLI and ABP to identify and, where practicable, implement measures reducing risks around the beach and breakwater.

    Stated by Neath Port Talbot County Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.
  2. 2

    Continue providing lifeguarding along Aberavon beach in line with current RNLI recommendations.

    Stated by Neath Port Talbot County Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
  3. 3

    Share RNLI’s assessment of identified beach risks with ABP.

    Stated by Neath Port Talbot County Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  4. 4

    Work collaboratively with Neath Port Talbot Council and Association British Ports to address the Coroner’s concerns.

    Stated by Royal National Lifeboat InstitutionStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  5. 5

    Continue influencing, supervising and educating people about coastal safety, explaining risks and sharing safety knowledge.

    Stated by Royal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.
  6. 6

    Deploy an additional security officer to monitor the whole Port Talbot Estate during summer months.

    Stated by Associated British PortsStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.

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

  1. 1

    Universal lifeguarding cannot be provided because the coastline and number of beaches make it impracticable, even if lifeguarding were legally required.

    Stated by Royal National Lifeboat InstitutionUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Continue collaborating with RNLI and ABP to identify and, where practicable, implement measures reducing risks around the beach and breakwater.

Verbatim wording from the response

“NPTCBC will continue its dialogue with RNLI in particular but also with ABP. NPTCBC will be led by RNLI’s recommendations in view of their nationally recognised expertise and will continue to address recommendations as far as is practicable within resource and budgetary constraints. ABP’s engagement with RNLI as to provision of services on the breakwater itself is beyond NPTCBC’s knowledge.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 2 · response
Published 11 June 2025

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 providing lifeguarding along Aberavon beach in line with current RNLI recommendations.

Verbatim wording from the response

“RNLI undertook its own beach safety assessment upon its engagement to provide services and since then has been provided with funding to implement the recommended level of services.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 4 · response
Published 11 June 2025

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

Share RNLI’s assessment of identified beach risks with ABP.

Verbatim wording from the response

“NPTCBC will of course share assessment of the risks identified along the beach in RNLI’s assessment with APB.”

Source location

Response from NEATH PORT TALBOT COUNCIL
Page 3 · response
Published 11 June 2025

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

Work collaboratively with Neath Port Talbot Council and Association British Ports to address the Coroner’s concerns.

Verbatim wording from the response

“2. We will work collaboratively with Neath Port Talbot Council and Association British Ports given the Coroner’s concerns.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 2 · response
Published 11 June 2025

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 influencing, supervising and educating people about coastal safety, explaining risks and sharing safety knowledge.

Verbatim wording from the response

“Further the RNLI acknowledges that anyone can drown but no one should, and David’s death was a tragedy. The RNLI is a charity that works to end preventable drowning, and we will continue to influence, supervise and educate people and explain the risks and share safety knowledge with anyone going out to sea or to the coast.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 4 · response
Published 11 June 2025

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

Deploy an additional security officer to monitor the whole Port Talbot Estate during summer months.

Verbatim wording from the response

“For a second successive year, Associated British Ports has deployed an additional security officer to monitor the whole of the Port Talbot Estate during the summer months.”

Source location

Response from ASSOCIATED BRITISH PORTS
Page 2 · response
Published 11 June 2025

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

Universal lifeguarding cannot be provided because the coastline and number of beaches make it impracticable, even if lifeguarding were legally required.

Verbatim wording from the response

“As discussed at the inquest there is no statutory requirements for a landowner to contract for a beach lifeguard service. Even if it was a statutory requirement, it is improbable or more accurately impossible, that all beaches could be lifeguarded and even if they were it would be for defined seasons and defined times of day.”

Source location

Response from ROYAL NATIONAL LIFEBOAT INSTITUTION
Page 2 · response
Published 11 June 2025

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