Andrew James Rees · Prevention of Future Deaths report

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Issued 9 Jan 2024•Avon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

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. Insufficiency of visual inspection for identifying deteriorating rescue chains
  2. Lack of formal assessment of changes in use triggering Port Marine Risk Assessment review

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Boatfolk Marinas Limited

    Increase visual chain inspections from monthly to weekly and record them in the inspection management system.

  2. Boatfolk Marinas Limited

    Introduce monthly physical pull tests for each chain and record them in the inspection management system.

  3. North Somerset Council

    Conduct annual risk assessments and review the assessment when specified trigger events, including changes of use, occur.

  4. North Somerset Council

    Update the Port Marine, Portishead risk assessment to formalize annual assessments and reviews triggered by specified changes, including change of use.

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

  1. North Somerset Council

    The evidence does not show that change of use lacked formal assessment or that current circumstances create an ongoing risk of further deaths.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. North Somerset Council

    Existing risk assessments, audits and review triggers, including annual review and changes of use or incidents, are considered sufficient to manage the area’s risk.

    Existing 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

Insufficiency of visual inspection for identifying deteriorating rescue chains

Wider context from the report

“(1) Boatfolk Marinas Ltd only In evidence it was identified that, in the vicinity of where the deceased was retrieved from the water, the rescue chain on the wall of the marina was broken and that the system of visual inspection in place for Boatfolk Marinas Ltd had not identified this. Whilst a monthly, documented visual inspection has been introduced it is a concern that visual inspection alone may be insufficient to identify the risk of a deteriorating chain. ”

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 formal assessment of changes in use triggering Port Marine Risk Assessment review

Wider context from the report

“(2) North Somerset Council only During the course of evidence one of the triggers to generate a review of the Port Marine, Portishead Risk Assessment by North Somerset Council was stated to be a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent. ”

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

Increase visual chain inspections from monthly to weekly and record them in the inspection management system.

Verbatim wording from the response

“We have increased the frequency of our visual inspection of the chains from monthly to weekly and have added a further physical 'pull' test that will take place on each chain on a monthly basis. As with all our inspections, both inspections will be recorded on our inspection management system.”

Source location

Response from Boatfolk
Page 1 · response
Published 19 January 2024

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

Introduce monthly physical pull tests for each chain and record them in the inspection management system.

Verbatim wording from the response

“We have increased the frequency of our visual inspection of the chains from monthly to weekly and have added a further physical 'pull' test that will take place on each chain on a monthly basis. As with all our inspections, both inspections will be recorded on our inspection management system.”

Source location

Response from Boatfolk
Page 1 · response
Published 19 January 2024

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 annual risk assessments and review the assessment when specified trigger events, including changes of use, occur.

Verbatim wording from the response

“8. The latest risk assessment which was put forward at the inquest hearing in evidence had a review date of February 2024. This date was set to allow North Somerset Council to reflect on any aspects of the inquest evidence and taking into consideration that until disclosure of the inquest bundle took place, just days before the commencement of the inquest on 9 January 2024, North Somerset Council had no indication of the actual facts surrounding this incident. In line with the written risk assessment and the evidence given at the inquest itself this risk assessment has been further reviewed and we attach a copy of it to this letter. This shows that there will be an annual risk assessment and that risk assessment review will be triggered in a number of circumstances, including any change of use of the area.”

Source location

Response from Clyde&Co
Page 2 · response
Published 19 January 2024

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 the Port Marine, Portishead risk assessment to formalize annual assessments and reviews triggered by specified changes, including change of use.

Verbatim wording from the response

“8. The latest risk assessment which was put forward at the inquest hearing in evidence had a review date of February 2024. This date was set to allow North Somerset Council to reflect on any aspects of the inquest evidence and taking into consideration that until disclosure of the inquest bundle took place, just days before the commencement of the inquest on 9 January 2024, North Somerset Council had no indication of the actual facts surrounding this incident. In line with the written risk assessment and the evidence given at the inquest itself this risk assessment has been further reviewed and we attach a copy of it to this letter. This shows that there will be an annual risk assessment and that risk assessment review will be triggered in a number of circumstances, including any change of use of the area.”

Source location

Response from Clyde&Co
Page 2 · response
Published 19 January 2024

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 evidence does not show that change of use lacked formal assessment or that current circumstances create an ongoing risk of further deaths.

Verbatim wording from the response

“‘During the course of evidence one of the triggers to generate a review of the Port Marine, Portishead Risk Assessment by North Somerset Council was stated to be a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent.’”

Source location

Response from Clyde&Co
Page 1 · response
Published 19 January 2024

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 risk assessments, audits and review triggers, including annual review and changes of use or incidents, are considered sufficient to manage the area’s risk.

Verbatim wording from the response

“1. There was considerable evidence about previous risk assessments, reviews and audits of the area between at least 2008 and 2023, with copies of the same provided to the court and explained, where necessary, in lengthy statements and oral evidence. Those assessments had clearly taken into account present and proposed use of the area and demonstrated a formal measure of change of use.”

Source location

Response from Clyde&Co
Page 2 · response
Published 19 January 2024

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