PFD report

Martin Edward ELLIS · Prevention of Future Deaths report

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Issued 13 Feb 2020•Inner North London

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised6

  1. Failure to prevent public access to the dam
    Part of recurring concern: Failure to prevent public access to closed or restricted hazardous sites
  2. Failure of construction workers to warn visitors away from the dam
  3. Failure to provide the Chief Electrical Officer’s investigation report
    Part of recurring concern: Unreliable safety investigation reports and disclosure
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 prevent public access to the dam

Wider context from the report

“1. The dam is apparently not open to members of the public, but Mr Ellis and his family were able to visit it with ease, not even knowing that it was restricted, still less having access prevented. ”

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

Failure of construction workers to warn visitors away from the dam

Wider context from the report

“3. I accepted evidence in court that construction workers did not warn the family off visiting the dam, but rather gave them directions on how to get there and where to park their car. ”

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 provide the Chief Electrical Officer’s investigation report

Wider context from the report

“4. The electrocution was caused by exposed live wiring in a galvanised metal conduit. I understand that the Chief Electrical Officer visited the site in the days after Mr Ellis’s death and that the Ministry of Infrastructure, Ports, Energy and Labour is responsible for the Saint Lucia investigation. However, six months after Mr Ellis’s death, no explanation has been provided to his family or to HM Senior Coroner for Inner North London, as to why there was an exposed live wire. Despite repeated requests, neither Mr Ellis’s family nor I have been provided with a copy of the Chief Electrical Officer’s report. 5. The dam was built in 1996. I do not know whether the unsafe wiring is a result of a lack of appropriate building regulations enforcement. I do not know whether other constructions built at around the same time are unsafe. ”

Is this part of a recurring concern?

Yes — Unreliable safety investigation reports and disclosure.

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 maintain a visible warning sign at the dam

Wider context from the report

“2. I found at inquest that the only warning sign was old, in poor repair and covered by foliage, so could not be seen. ”

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 provide an explanation for exposed live wiring

Wider context from the report

“4. The electrocution was caused by exposed live wiring in a galvanised metal conduit. I understand that the Chief Electrical Officer visited the site in the days after Mr Ellis’s death and that the Ministry of Infrastructure, Ports, Energy and Labour is responsible for the Saint Lucia investigation. However, six months after Mr Ellis’s death, no explanation has been provided to his family or to HM Senior Coroner for Inner North London, as to why there was an exposed live wire. Despite repeated requests, neither Mr Ellis’s family nor I have been provided with a copy of the Chief Electrical Officer’s report. 5. The dam was built in 1996. I do not know whether the unsafe wiring is a result of a lack of appropriate building regulations enforcement. I do not know whether other constructions built at around the same time are unsafe. ”

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

Exposed live wiring at the dam

Wider context from the report

“4. The electrocution was caused by exposed live wiring in a galvanised metal conduit. I understand that the Chief Electrical Officer visited the site in the days after Mr Ellis’s death and that the Ministry of Infrastructure, Ports, Energy and Labour is responsible for the Saint Lucia investigation. However, six months after Mr Ellis’s death, no explanation has been provided to his family or to HM Senior Coroner for Inner North London, as to why there was an exposed live wire. Despite repeated requests, neither Mr Ellis’s family nor I have been provided with a copy of the Chief Electrical Officer’s report. 5. The dam was built in 1996. I do not know whether the unsafe wiring is a result of a lack of appropriate building regulations enforcement. I do not know whether other constructions built at around the same time are unsafe. ”

Is this part of a recurring concern?

Yes — Uncontrolled hazards from defective electrical wiring and installations.

Open source report
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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

No official response is included in the current published snapshot.