PFD report

Ava-May LITTLEBOY · Prevention of Future Deaths report

Get email alerts

Request correction

Issued 2 Apr 2020•Norfolk

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: 4
Recipients: 1
Responses found: 3
Stated actions: 4

Recipients and published responses

British Standards InstitutionResponse found

Source document

Full report text

This is the full text from the original published report.

Open published report

Investigation and inquest

On 13 September 2018 I commenced an investigation into the death of Ava-May LITTLEBOY aged 3 years.
The investigation concluded at the end of the inquest, held with a jury, on 19 March 2020. The medical
cause of death was:
1a Traumatic Head Injury
The conclusion of the inquest was: Ava-May’s guardians paid for the use of a trampoline which exploded
following which she died

Coroner’s concerns

1. Evidence was heard that it is required a device will be inspected by an independent third party and,
provided it satisfies relevant requirements, it will be certified under the Amusement Device Inspection
Procedures Scheme (ADIPS) (or Pertexa Inflatable Play Equipment (PIPA) or another testing scheme or
method which demonstrates how such procedures equal or better the accepted best practice) as safe
to operate and a Declaration of Operational Compliance (DOC) will be issued. If the device is not
deemed fit to use, then the device is categorised according to the defect or concern raised which may
result in a DOC not being issued and the operator advised not to use the equipment until the defect has
been rectified.
The inflatable trampoline had been acquired in August/September 2017 and was inspected by an
independent company on 26 June 2018 (namely 4 days prior to the trampoline exploding). Concerns
were raised by the independent company with regard to no pre-use manufacturing paperwork being
available and that not all Tie Downs were being used. Evidence was heard that had the trampoline been
registered under ADIPS a Category A defect would apply, namely that the device is considered as being
of imminent danger to persons and that the device should not be used until those defects have been
rectified. As such, a DOC would not have been issued and it would have been clear that the trampoline
was not fit to be used.
However, as the trampoline had not been registered under ADIPS (or PIPA or an independent scheme),
the issues could not be categorised and it would not be recorded in any public domain that a DOC had
not been issued.
2. Further, there is no requirement that the relevant enforcing authority, for instance Health and Safety
Executive or the Local Authority is informed that the equipment is deemed unsafe to use.
3. The evidence also revealed that there is no legal requirement for an Operator to use either the ADIPS
or PIPA inspection process but can rely on an alternative form of scheme or method of their own
choosing to demonstrate the device is safe to use.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

Failure to require registration under an approved equipment inspection scheme
Failure to require operators to use a recognised inspection process
Failure to require notification of enforcing authorities when equipment is deemed unsafe to use

Responses linked to these concerns

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

Actions described in response 2

Action
Publish and maintain guidance on safe practice for fairground and amusement devices.
Stated by Health and Safety ExecutiveStated completed
Action
Remind industry stakeholders of their obligations and signpost relevant safety information following the incident.
Stated by Health and Safety ExecutiveStated completed

Respondent positions 3

Position
Regulatory and enforcement action to prevent recurrence falls outside the functions and authority of a national standards body.
Stated by British Standards InstitutionOutside remit

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 2

1
Continue working with entertainment and leisure industry stakeholders through the Amusement Safety Device Council to improve amusement-device safety.
Stated by Health and Safety ExecutiveStated in progress
2
Develop and publish additional guidance on designing, operating and inspecting sealed inflatable devices in consultation with the amusement industry.
Stated by Health and Safety ExecutiveStated in progress

Recipient positions 9

1
Concerns about the applicable law, guidance, or Inspection Body duties should be raised with HSE and the Amusement Devices Safety Council.
Stated by John H Rundle LimitedRedirects responsibility
2
The additional inflatables were not inspected; observations of tie-down use did not constitute an inspection or inspection findings.
Stated by John H Rundle LimitedDisputes the concern
3
Inspection Bodies are not responsible for advising on equipment setup, tie-down use, or operational safety beyond inspecting equipment condition.
Stated by John H Rundle LimitedOutside remit
4
Controllers and operators are responsible for following manufacturer instructions and checking tie-downs after setup, deflation, reinflation, and before use.
Stated by John H Rundle LimitedRedirects responsibility
5
Paper recording remained an accepted and effective alternative, so the uncharged iPad did not compromise the planned inspections.
Stated by John H Rundle LimitedExisting arrangements considered sufficient
6
The additional equipment could not be inspected because manufacturer, operating, maintenance, and previous inspection information was unavailable.
Stated by John H Rundle LimitedUnable to act
7
The incident device falls outside the relevant BS EN 14960 categories, so the corresponding HS(G)175 table recommendations do not apply.
Stated by Health and Safety ExecutiveDisputes the concern
8
Final responsibility for completing pre-use inspections and ensuring device safety rests with the controller, who may appoint an inspection body.
Stated by Health and Safety ExecutiveRedirects responsibility
9
The HS(G)175 pre-use inspection process provides a suitably robust framework for ensuring amusement devices are safe before public use.
Stated by Health and Safety ExecutiveExisting arrangements considered sufficient

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised4

Failure to require registration under an approved equipment inspection scheme

Failure to require operators to use a recognised inspection process

Failure to require notification of enforcing authorities when equipment is deemed unsafe to use

Failure to categorise equipment defects and publicly record non-issued compliance declarations

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

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.2

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.9

Actions described in response 2

Respondent positions 3

Recipient-stated actions 2

Recipient positions 9