PFD report

Kristopher John McDowell · Prevention of Future Deaths report

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Issued 7 Mar 2019•North Wales (East and Central)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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. Excessive spacing between aqueduct parapet uprights
    Part of recurring concern: Inadequate physical barriers preventing access to dangerous drops or areas
  2. Failure of upright embedment testing to provide accurate and regular assessments
    Part of recurring concern: Unreliable annual safety inspection processes
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.4

  1. Action

    Inspect each aqueduct upright and check its engagement during the forthcoming Principal Inspection, compare results with 2016 findings, and review future checking frequency.

    Stated by Canal & River TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  2. Action

    Investigate physical options for reducing gaps between the aqueduct uprights with relevant partners and regulatory bodies.

    Stated by Canal & River TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  3. Action

    Develop and submit a final design for reducing the gaps between the uprights for statutory approval after consultation.

    Stated by Canal & River TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing signage, volunteer ranger and information controls adequately address risks associated with normal aqueduct use.

    Stated by Canal & River TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Excessive spacing between aqueduct parapet uprights

Wider context from the report

“(a) The average space between the uprights on the parapet on the aqueduct is 195mm whilst the current industry standard is 110mm as a result of which there exists a risk that a person might be able to pass between them. This is a particular risk for children using the aqueduct but it is also a significant risk for young persons or adults being of sufficient width for them to pass through in circumstances whereby it was their intention to gain access to the non-pedestrian side of the parapet for a purpose which would not be considered the intended use of the structure. In my opinion, the use of signage alone, warning users of the potential risk, does not adequately mitigate the risk of a person passing through the uprights and falling from the aqueduct. (b) Evidence provided by an expert instructed by the Canal and River Trust (CRT) indicated that it was his belief that the upright became detached as a result of a lifting action which dis-engaged the nib on the bottom of the upright from the socket on the outside of the parapet. The evidence provided to the inquest by engineers from CRT advised that their inspection procedures provided for an Annual Inspection which included testing for the extent of embedment by a push/pull/lift test, however in my opinion the subjective elements of this test would permit inconsistencies in the information which it provides. Furthermore, exact measurements of the degree of embedment of uprights would only routinely be established in the course of a Principal Inspection which takes place every twenty years and as a result it is difficult for there to be an accurate/regular assessment of the rates of possible deterioration and hence the true extent of embedment. In my opinion, the testing processes currently adopted (in regard to the matters detailed above) are inadequate to ensure that the uprights are properly engaged at all times. ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

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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 upright embedment testing to provide accurate and regular assessments

Wider context from the report

“(a) The average space between the uprights on the parapet on the aqueduct is 195mm whilst the current industry standard is 110mm as a result of which there exists a risk that a person might be able to pass between them. This is a particular risk for children using the aqueduct but it is also a significant risk for young persons or adults being of sufficient width for them to pass through in circumstances whereby it was their intention to gain access to the non-pedestrian side of the parapet for a purpose which would not be considered the intended use of the structure. In my opinion, the use of signage alone, warning users of the potential risk, does not adequately mitigate the risk of a person passing through the uprights and falling from the aqueduct. (b) Evidence provided by an expert instructed by the Canal and River Trust (CRT) indicated that it was his belief that the upright became detached as a result of a lifting action which dis-engaged the nib on the bottom of the upright from the socket on the outside of the parapet. The evidence provided to the inquest by engineers from CRT advised that their inspection procedures provided for an Annual Inspection which included testing for the extent of embedment by a push/pull/lift test, however in my opinion the subjective elements of this test would permit inconsistencies in the information which it provides. Furthermore, exact measurements of the degree of embedment of uprights would only routinely be established in the course of a Principal Inspection which takes place every twenty years and as a result it is difficult for there to be an accurate/regular assessment of the rates of possible deterioration and hence the true extent of embedment. In my opinion, the testing processes currently adopted (in regard to the matters detailed above) are inadequate to ensure that the uprights are properly engaged at all times. ”

Is this part of a recurring concern?

Yes — Unreliable annual safety inspection processes.

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

Inspect each aqueduct upright and check its engagement during the forthcoming Principal Inspection, compare results with 2016 findings, and review future checking frequency.

Verbatim wording from the response

“Notwithstanding this, we are not complacent and are very concerned that there should be public confidence in our stewardship of the Aqueduct. During the forthcoming Principal Inspection which will be undertaken this year, the condition of each of the uprights will be inspected and the engagement will be checked again. We will compare this result with the 2016 inspection and consider further what the frequency of future checking needs to be. The inspection and the review will be completed by early 2020.”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 4 · response
Published 9 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

Investigate physical options for reducing gaps between the aqueduct uprights with relevant partners and regulatory bodies.

Verbatim wording from the response

“The Trust has also given further careful thought to this issue raised in your report. It also bears in mind, and has high regard to, the perception by the public of the safety of its structures. Our ambitions and those of our partners for the World Heritage Site are to see it protected and celebrated, drawing increasing numbers of visitors. The significant heritage status of the Aqueduct, including the parapet, means that the Trust must seek explicit consent from the Welsh Government through CADW (the Welsh Government's historic environment service) before carrying out any works to the structure with any permanent changes to the appearance of the Aqueduct likely to be of particular concern. As visitor safety – and perception of safety - remains our paramount concern, we have decided to explore with CADW and our other partners how the”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 2 · response
Published 9 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

Develop and submit a final design for reducing the gaps between the uprights for statutory approval after consultation.

Verbatim wording from the response

“• For example, at Marple Aqueduct which was referred to at the Inquest, we undertook an informal public consultation relating to the options which guided the final design and, we believe, eased the consenting process. We will expect to do the same here and need to allow sufficient time for this; our outline plan is for this consultation to be conducted later in 2019 and completed by early 2020;”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 3 · response
Published 9 June 2019

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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 an informal public consultation on suitable options for reducing the gaps between the uprights.

Verbatim wording from the response

“• We have started an investigation of the physical options available to address gaps between the uprights, working with relevant partners and regulatory bodies. We aim to have this completed by the end of September 2019. If we conclude there is more than one physical option that is suitable (taking into account the physical integrity of the Aqueduct) to reduce the width of the gaps then we will proceed to the consultation process referred to immediately below this bullet point;”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 3 · response
Published 9 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

Existing signage, volunteer ranger and information controls adequately address risks associated with normal aqueduct use.

Verbatim wording from the response

“Given the Aqueduct’s extraordinary heritage significance, the Trust has deliberately sought to manage the risk of anyone passing between the gaps by non-invasive controls to minimise any impact on the original aqueduct design. As stated in evidence to the Inquest, the Trust uses warning signage to advise visitors prior to them accessing the structure, and through the use of volunteer rangers at peak times and by appropriate information found on the Trust’s website. The signage is installed in prominent locations on the approach to the parapet and on “repeater” posts installed in the towpath. The Trust has identified the risk of unsupervised young children in relation to the gaps, and specifically addresses this in the warning signage. During the course of your investigation, these signs were enhanced by the Trust to advise dog owners that dogs should be kept on a lead.”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 2 · response
Published 9 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

The existing risk-based inspection regime is proportionate and repeatable, with training, checking and peer review ensuring consistency.

Verbatim wording from the response

“Our inspection processes are determined from a risk-based approach that balances likelihood and consequence of a failure, and considers issues such as the material properties of the railing and the known low rates of degradation. The 2016 Special Inspection confirmed that all of the uprights were sufficiently engaged.”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 4 · response
Published 9 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.1

  1. 1

    Install enhanced warning signs discouraging people from climbing on or passing through the aqueduct uprights.

    Stated by Canal & River TrustStated completedThe respondent said that this action was complete when they made their response on 9 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

Install enhanced warning signs discouraging people from climbing on or passing through the aqueduct uprights.

Verbatim wording from the response

“You have asked us to consider a degree of abnormal use and we bear in mind that, at the Inquest, the family’s representative stated that locally it is believed that young adults have on occasions put themselves deliberately at risk by passing between the uprights. The Trust was not aware of this and has no records, reports or sightings of individuals acting in this way prior to the incident. In our preliminary consideration of your report, we have recognised that further warning signage can be used to reinforce the safety message on the approach to the Aqueduct. We attach photographs of the new signage which has been installed specifically warning and discouraging people from climbing on or through the uprights.”

Source location

2019-0083-Response-by-Canal-River-Trust
Page 2 · response
Published 9 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