PFD report

Gillian Louisa DAVEY and Michael PENDER · Prevention of Future Deaths report

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Issued 28 May 2020•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.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
12

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. Lack of publicly available information on planned lifeguard patrol locations and timing
    Part of recurring concern: Unreliable public information about beach lifeguard coverage
  2. Unavailability of professional lifeguard cover on Cornwall beaches
    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.2

  1. Action

    Revise and expand summer RNLI lifeguard coverage by working with landowners and councils to confirm additional beach cover.

    Stated by Royal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2020.
  2. Action

    Make public announcements detailing confirmed beaches and timings for the lifeguard-service rollout.

    Stated by Royal National Lifeboat InstitutionStated plannedThe respondent said that this action was planned when they made their response on 30 July 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Landowners, rather than the RNLI, are responsible for assessing public beach-use risks and providing or arranging lifeguarding.

    Stated by Royal National Lifeboat InstitutionRedirects 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

Lack of publicly available information on planned lifeguard patrol locations and timing

Wider context from the report

“On the day of these incidents, there was no lifeguard cover on any Cornish beach. How this state of affairs arose will be a matter for the future. My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing. I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity. Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life. ”

Is this part of a recurring concern?

Yes — Unreliable public information about beach lifeguard coverage.

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

Unavailability of professional lifeguard cover on Cornwall beaches

Wider context from the report

“On the day of these incidents, there was no lifeguard cover on any Cornish beach. How this state of affairs arose will be a matter for the future. My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing. I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity. Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life. ”

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

Revise and expand summer RNLI lifeguard coverage by working with landowners and councils to confirm additional beach cover.

Verbatim wording from the response

“Our original plan was to have lifeguard patrols on 70 beaches this summer. It was a conservative plan and made and announced when many things were still unknown. We now have a better idea of the journey out of lockdown for all parts of the UK, understand the new regulations with which we must comply as an employer and service provider and, most importantly, feel we can properly manage the risks associated with coronavirus. We were on 18 beaches last weekend, 8 of which are in Cornwall, and we are revising our original plans and exploring which additional beaches we can lifeguard this summer. To this end, we are working hard with 55 landowners and local councils to ensure as many beaches as possible will have RNLI lifeguard cover.”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 2 · response
Published 30 July 2020

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

Make public announcements detailing confirmed beaches and timings for the lifeguard-service rollout.

Verbatim wording from the response

“With so many local landowners to work with, and so many dependencies, it will take time to confirm individual beaches and timings, but we will make public announcements more detail over the next few weeks.”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 2 · response
Published 30 July 2020

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, rather than the RNLI, are responsible for assessing public beach-use risks and providing or arranging lifeguarding.

Verbatim wording from the response

“I appreciate your concerns about the prevention of future deaths. Further, I also appreciate that in accordance with Chief Coroner’s Guidance No. 5, you may issue a Regulation 28 Report before an inquest is concluded. However, in this instance I believe the Regulation 28 Report is premature and has been made without the benefit of all the relevant information; this includes the fact it is the landowner, not the RNLI, who has the responsibility to carry out risk assessments covering the public use of beaches, and then to mitigate the risks they identify by, amongst other things, providing a lifeguarding service.”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 1 · response
Published 30 July 2020

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 deaths cannot yet be attributed to the absence of lifeguards because the inquest must determine causation.

Verbatim wording from the response

“As you set out in paragraph 5 of your report, your request is based upon the fact you believe that, unless lifeguarding services are back on beaches, there will inevitably be a further loss of life. This pre-supposes that both deaths were caused by a lack of lifeguards, which of course will require an inquest to determine.”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 1 · response
Published 30 July 2020

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

Beach safety is outside the agency’s statutory or specific responsibilities.

Verbatim wording from the response

“The Department for Transport and the Maritime & Coastguard Agency have an interest in maritime safety generally because we want to see fewer accidents and less demand on the emergency services that we coordinate to respond to search and rescue missions. That is why we promote initiatives such as the annual Maritime Safety Week alongside partner organisations and we use our social media and other channels to communicate safety campaigns and messages. We do not have any statutory or specific responsibilities for beach safety.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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 services cannot provide an absolute guarantee of beach safety because they are limited in coverage, hours and seasonality.

Verbatim wording from the response

“Fundamentally and ultimately, however, people have a personal responsibility for their own safety in and around water and on beaches. Landowners, local authorities and others can provide safety information including signage and public rescue equipment, but it is individuals taking responsibility for their own safety and actions that will keep most people safe. Even where beach owners carry out a risk assessment and conclude that they can support safety by providing a lifeguarding service, whether from the RNLI or another provider, those services will not operate 24 hours a day and always cover just a limited area of each beach. Deployment will also be seasonal to take account of the times of year when the risk is judged to be at its highest. The provision of a lifeguarding service is not, and can never be, an absolute guarantee of safety.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 3 · response
Published 30 July 2020

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

Beach safety and lifeguarding provision fall outside the respondent’s remit, which is limited to coordinating coastal and sea search-and-rescue responses.

Verbatim wording from the response

“In your report, under Section 6, you say that the Department for Transport, the RNLI and the Maritime and Coastguard Agency (MCA) have the powers to take action in respect to providing a lifeguard service on beaches in Cornwall, to help prevent the future loss of life. The MCA, which includes Her Majesty’s Coastguard, is an executive Agency of the Department for Transport. I am therefore replying on my own behalf, and also on behalf of the Secretary of State for Transport, the Right Honourable Grant Shapps MP. The MCA has a responsibility to respond to calls for assistance as the emergency responder with the remit for search and rescue at the coast and at sea. Our role is to coordinate the emergency response drawing from the matrix of search and rescue resources that are available and appropriate. However, we have no remit for beach safety or the provision of lifeguarding.”

Source location

2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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.10

  1. 1

    Continue widespread preventive media messaging and signage about beach safety.

    Stated by Royal National Lifeboat InstitutionStated completedThe respondent said that this action was complete when they made their response on 30 July 2020.
  2. 2

    Publish the independent beach-safety review on gov.uk.

    Stated by Maritime and Coastguard AgencyStated plannedThe respondent said that this action was planned when they made their response on 30 July 2020.
  3. 3

    Commission and complete an independent review of beach safety legal responsibilities and recommendations.

    Stated by Maritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 30 July 2020.
  4. 4

    Continue partner safety campaigns and messaging, including the joint RNLI campaign on coastal safety, beach inflatables and contacting the Coastguard.

    Stated by Maritime and Coastguard AgencyStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2020.
  5. 5

    Update and publish the Beach Safety Guide, providing a framework for beach owners to assess risks and mitigations.

    Stated by Maritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 30 July 2020.
  6. 6

    Discuss the review’s remaining recommendations with stakeholders and seek wider debate about possible next steps.

    Stated by Maritime and Coastguard AgencyStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2020.
  7. 7

    Develop and publish pandemic beach-safety guidance for the public and staff with RoSPA and the RNLI.

    Stated by Maritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 30 July 2020.
  8. 8

    Promote beach safety messages, including campaigns for members of the public visiting beaches.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2020.
  9. 9

    Send additional HM Coastguard vehicle patrols to known coastal safety hotspots for surveillance and faster search-and-rescue response.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2020.
  10. 10

    Produce guidance to help beach-safety landowners assess and mitigate risks to public beach users.

    Stated by Department for TransportStated completedThe respondent said that this action was complete when they made their response on 30 July 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    The RNLI considers the report premature because the coroner has not received all relevant documents, evidence and information.

    Stated by Royal National Lifeboat InstitutionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Firm conclusions on the remaining beach-safety recommendations cannot yet be reached because wider policy discussions were delayed and require extensive consideration.

    Stated by Maritime and Coastguard AgencyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    Relevant beach owners are responsible for assessing public beach-use risks and mitigating the risks identified.

    Stated by Department for TransportRedirects 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

Continue widespread preventive media messaging and signage about beach safety.

Verbatim wording from the response

“I have only set out the plans for the current and future rollout of lifeguarding, but I can provide information as to the reasons why RNLI lifeguarding services were not on the Cornish beaches at the time of the two tragic deaths, along with some of the other preventative steps that had, and will continue to be taken, including widespread media messaging and signage. This can be provided in due course for the inquest.”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 2 · response
Published 30 July 2020

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 independent beach-safety review on gov.uk.

Verbatim wording from the response

“Ministerial appointments and portfolios were confirmed at the end of February 2020 and soon after new Ministers had been briefed about the most pressing issues that needed to be at the top of their priorities, attention necessarily focused on the coronavirus pandemic. The opportunity to consider the independent review has now been taken and we intend to publish it on gov.uk as soon as possible. Ministers are seeking a wider debate about the merits of the remaining recommendations and we will be discussing these with stakeholders with a view to gauging opinion on possible next steps.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 2 · response
Published 30 July 2020

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

Commission and complete an independent review of beach safety legal responsibilities and recommendations.

Verbatim wording from the response

“After the deaths at Camber Sands in 2016 and the helpful observations from Mr Craze, the East Sussex Coroner, the Maritime & Coastguard Agency, working closely with the wider membership of the National Water Safety Forum, commissioned a review from an independent lawyer. We asked him to undertake research to form a view of beach safety in terms of legal responsibilities and to make recommendations.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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 partner safety campaigns and messaging, including the joint RNLI campaign on coastal safety, beach inflatables and contacting the Coastguard.

Verbatim wording from the response

“For our part in the Maritime & Coastguard Agency we will continue to work with partners on safety campaigns and messaging using social media and paid advertising. At the moment we are engaged in a joint campaign with the RNLI to encourage coastal safety, discourage people from using inflatables at the beach, and to remind them that if they do get into difficulty then they should call 999 for the Coastguard.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 3 · response
Published 30 July 2020

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 and publish the Beach Safety Guide, providing a framework for beach owners to assess risks and mitigations.

Verbatim wording from the response

“The research was completed by Dominic Watkins at DWF who took time to test out his thinking with a wide range of stakeholders. A review was completed, and recommendations made. One immediate action, to update a Beach Safety Guide that was originally published in the 1990s, was completed quickly by the Maritime & Coastguard Agency. The Guide provides a framework for beach owners to use when considering risks to the public at their beaches and advice on mitigations that might be”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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

Discuss the review’s remaining recommendations with stakeholders and seek wider debate about possible next steps.

Verbatim wording from the response

“Ministerial appointments and portfolios were confirmed at the end of February 2020 and soon after new Ministers had been briefed about the most pressing issues that needed to be at the top of their priorities, attention necessarily focused on the coronavirus pandemic. The opportunity to consider the independent review has now been taken and we intend to publish it on gov.uk as soon as possible. Ministers are seeking a wider debate about the merits of the remaining recommendations and we will be discussing these with stakeholders with a view to gauging opinion on possible next steps.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 2 · response
Published 30 July 2020

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

Develop and publish pandemic beach-safety guidance for the public and staff with RoSPA and the RNLI.

Verbatim wording from the response

“The research was completed by Dominic Watkins at DWF who took time to test out his thinking with a wide range of stakeholders. A review was completed, and recommendations made. One immediate action, to update a Beach Safety Guide that was originally published in the 1990s, was completed quickly by the Maritime & Coastguard Agency. The Guide provides a framework for beach owners to use when considering risks to the public at their beaches and advice on mitigations that might be”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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

Promote beach safety messages, including campaigns for members of the public visiting beaches.

Verbatim wording from the response

“Alongside the RNLI and other sea safety charities, we promote safety messages including specific campaigns aimed at the general public for when they go to the beach. Those messages are designed to help save lives and to reduce the call on resources. The relevant beach owner, which can be a local authority, sometimes the National Trust and many private owners have the responsibility to carry out risk assessments covering public use of beaches and then to mitigate the risks they identify. To help landowners”

Source location

2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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

Send additional HM Coastguard vehicle patrols to known coastal safety hotspots for surveillance and faster search-and-rescue response.

Verbatim wording from the response

“For our part, given that the RNLI and similar organisations may not have lifeguards on beaches, we are sending more HM Coastguard vehicle patrols to known safety hotspots for surveillance purposes, keeping a look out for any incidents at the coast enabling a swift response for search and rescue, should that be needed.”

Source location

2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 2 · response
Published 30 July 2020

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

Produce guidance to help beach-safety landowners assess and mitigate risks to public beach users.

Verbatim wording from the response

“Alongside the RNLI and other sea safety charities, we promote safety messages including specific campaigns aimed at the general public for when they go to the beach. Those messages are designed to help save lives and to reduce the call on resources. The relevant beach owner, which can be a local authority, sometimes the National Trust and many private owners have the responsibility to carry out risk assessments covering public use of beaches and then to mitigate the risks they identify. To help landowners”

Source location

2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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 RNLI considers the report premature because the coroner has not received all relevant documents, evidence and information.

Verbatim wording from the response

“As is set out above, I consider it very likely the RNLI will be required to provide you with evidence to allow you to fulfil your role. It is for this reason that, insofar as it relates to the RNLI, I consider the Regulation 28 Report to be premature. As you will be aware, paragraph 12 of the Chief Coroner’s Guidance No. 5 states that a”

Source location

2020-0121-Response-from-RNLI_Redacted.pdf
Page 1 · response
Published 30 July 2020

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

Firm conclusions on the remaining beach-safety recommendations cannot yet be reached because wider policy discussions were delayed and require extensive consideration.

Verbatim wording from the response

“We recognised that the remainder of the Review’s recommendations were wide-ranging and would need much more detailed discussion and consideration across many interest groups and government Departments. We had planned to make the Review public at a National Water Safety Forum event in November 2019 organised by the Royal Society for the Prevention of Accidents. Ministers were scheduled to introduce the Review and our plan was to use the occasion to start a wider consideration of the policy matters it contains. However, at the beginning of November the Prime Minister called a General Election for 12 December 2019. It is a convention within Government that all but essential policy announcements are deferred during the pre-election period, which meant that the Minister was no longer able to attend the Safety Conference and start the wider discussions.”

Source location

2020-0121-Further-response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 2 · response
Published 30 July 2020

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

Relevant beach owners are responsible for assessing public beach-use risks and mitigating the risks identified.

Verbatim wording from the response

“Alongside the RNLI and other sea safety charities, we promote safety messages including specific campaigns aimed at the general public for when they go to the beach. Those messages are designed to help save lives and to reduce the call on resources. The relevant beach owner, which can be a local authority, sometimes the National Trust and many private owners have the responsibility to carry out risk assessments covering public use of beaches and then to mitigate the risks they identify. To help landowners”

Source location

2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Page 1 · response
Published 30 July 2020

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