Neil Stewart
PFD Report
Historic (No Identified Response)
Ref: 2021-0400
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
11 Jan 2022
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
6. The following action is required to avoid future deaths: (1) Create and adopt a written safety policy/protocol in which you clearly document the steps you will put in place to protect your guests, your expectation of them and their conduct and a clear warning of the risks associated with the events they may attend (2) Create/adopt a written policy/protocol for providing services (entertainment) at a venue that is associated with risks unique/specific to that venue which should include bespoke warnings/guidance to be given to clients who attend.
(3) When providing entertainment services in venue where another provider is responsible for organisation, safety of guests – discuss with the provider the details and clearly document the distinction in those responsibilities and give guidance to guests accordingly
(3) When providing entertainment services in venue where another provider is responsible for organisation, safety of guests – discuss with the provider the details and clearly document the distinction in those responsibilities and give guidance to guests accordingly
Report Sections
Investigation and Inquest
On 13 December 2017 I commenced an investigation into the death of Neil James STEWART. The investigation concluded at the end of the inquest on 27 September 2021. The conclusion of the inquest was Accidental death by drowning. The medical cause of death was: 1a Drowning
1b 1c
1b 1c
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Ensure immediate HART resource deployment
Manchester Arena Inquiry
Emergency contingency plans
Outdated Operational Guidance
Re-draft fire brigade calling instructions for staff in plain English
Fennell Inquiry
Emergency contingency plans
Outdated Operational Guidance
Apply best offer principle equally in GLOS
Post Office Horizon Inquiry
Outdated Operational Guidance
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Outdated Operational Guidance
Set deadline for HSS claims with guidance on late applications
Post Office Horizon Inquiry
Outdated Operational Guidance
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Outdated Operational Guidance
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.