Other related deaths

Noted (AI summary) Derbyshire County Council is exploring the feasibility of removing an access bridge to reduce flood risk and constructing a Flood Alleviation Scheme on the Spital Brook. They will also continue to work collaboratively with the Environment Agency to encourage residents to sign up for flood warnings and review existing flood plans and evacuation procedures. The Environment Agency expresses condolences and explains that while they have powers to build flood defences, they are not able to eliminate the risk of flooding entirely. They will continue to work with communities and provide a Flood Warning Service and carry out winter maintenance walkovers. Defra acknowledges the concerns and highlights its national responsibility for flood risk management. The Minister will meet with representatives from Derbyshire County Council and the Environment Agency to discuss flood protection in Chesterfield ahead of winter.

Noted (AI summary) Total Security Services clarifies that its security officer was not employed as a first-aider and it's not contractually required by Tesco for security officers to provide first aid. The company expects its employees to follow their SIA licence training and will conduct monthly audits to ensure that all its employees continue to hold valid licences that have neither been revoked nor expired. Tesco will deliver "Appointed Person" training to approximately 30,000 UK store management colleagues starting December 1, 2025, with completion by February 28, 2026. This training will provide managers with the skills to relay information to Ambulance Control, follow their instructions, and administer basic first aid when directed. The Security Industry Authority (SIA) investigated the training and conduct of the security operative and Total Security Services Limited, and will consider regulatory action if necessary. They have also offered expert witness assistance to coroners in relevant inquests.

Noted (AI summary) The CAA concludes that no change to the existing aviation safety regulation framework is currently required, given safeguards in place related to airworthiness and operational regulations, design and certification requirements and operator safety management systems; however, it will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks. The CAA concludes that no change to the existing aviation safety regulation framework is currently required, given safeguards in place related to airworthiness and operational regulations, design and certification requirements and operator safety management systems; however, it will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks. The DfT notes that ICAO has amended Annex 13 via SARP 5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated.

Noted (AI summary) The CAA has adopted updates to Acceptable Means of Compliance to CS-27 and CS-29 relating to rolling contact fatigue in critical bearings and initiated rulemaking projects to clarify the airworthiness status and life limits of critical parts and ensure the removal of defective critical parts from service. They will also engage with international counterparts to harmonise approach to critical bearing design and certification. EASA acknowledges the concerns raised in the Prevention of Future Death Report, referring to their assistance in the AAIB safety investigation and internal procedures for addressing safety recommendations. They state that they are considering introducing new AMC to CS 29.927(a) (Additional tests) to clarify the need to support inspection intervals and retirement times with appropriate directly applicable data, but believe the existing framework is adequate.

Noted (AI summary) The Department for Transport confirms that it is not the owner of the wreck and has no legal responsibility pertaining to it, as the wreck was sold to a private individual in 1957.

Noted (AI summary) The Minister will write to Swim England to explore how awareness of the 'Beyond Swim' accreditation scheme and associated guidance can be increased. They will also continue to work with sports bodies to ensure safety is prioritised. HSE acknowledges the concerns, explains that existing regulations (HSWA and MHSWR) apply to open water swimming events, and that relevant guidance is available from other sources. HSE will not be publishing specific guidance at this time but will raise awareness with local authority enforcement officers.

Noted (AI summary) The practice will adopt a protocol to ensure GPs do not treat immediate family members, according to GMC guidelines and current Good Medical Practice guidelines. The GMC acknowledges the coroner's concerns regarding a doctor treating a close relative, referencing their guidance that this should be avoided where possible but is not explicitly forbidden. They state that they will assess if the individual poses any current and ongoing risk.

Noted (AI summary) National Trading Standards explains their remit and states they do not have enforcement powers in this situation, recommending the Coroner contact other agencies. The HSE outlines the duties of letting agents under the Health and Safety at Work Act, but notes their undertaking is unlikely to extend to areas outside the property or managing tenant behaviour. They suggest the letting industry may wish to consider passing on information about risks beyond their direct undertaking. The agency will reinforce tenancy agreements to prohibit access to non-designated areas like roofs, issue written warnings for violations, and collaborate with Islington Council on tenant safety procedures.

Noted (AI summary) The UKHMA engaged with stakeholders and communicated findings to members, and brought the MAIB report to the PMSC steering group. They also proposed the inclusion of guidance in the GTGP, which is expected to be reviewed around Q3 2024. The RYA has delayed review of its "Small High Speed Passenger Vessel Voluntary Code of Practice" awaiting MCA legislation, and envisages releasing a revised edition soon after the MCA Sport and Pleasure Vessel Code is finalized. British Marine helped produce and publish the HSPV code in 2010, revised in 2019, and made its use a requirement of membership for operators carrying out this type of activity. The Department for Transport states that the MCA is prioritising an updated Sport or Pleasure Vessel Code, currently under public consultation. The MCA has also been tasked to commission an anthropometric assessment of small high-speed passenger craft safety, with results expected in late spring/early summer 2026. The British Standards Institution acknowledges the concern regarding BS EN ISO 11591 but clarifies its role as a facilitator for expert committees to develop standards, not to interpret or regulate them; BSI will refer the concerns to the relevant technical committee. The BPA acknowledges the concerns and has corresponded with the MAIB regarding guidance, stating the MCA should lead this. The BPA has offered to promote and amplify guidance, but is not insured to set safety-critical guidelines itself. Associated British Ports acknowledges the concerns but states that monitoring AIS tracks of vessels and intervening in their operation would be very challenging, require dedicated resources, and may not materially increase the safety of harbour users, also noting the limitations of their powers and resources for policing vessels. The MCA is working on an updated Sport or Pleasure Vessel Code, informed by the MAIB Investigation Report, which is currently undergoing public consultation. They have also begun procurement for an anthropometric assessment of small high-speed passenger craft safety, with a report expected in late spring/early summer 2026 to inform future code revisions and guidance. Red Bay Boats Limited has instructed Scot Seats to test seats to meet HSC 2000 standards; they recommend installation of Scot Seats where possible; they will not accept any commissions in the thrill-seeking market; and feel that sea safari craft should not exceed 25 knots. The UKMPG states it supports information sharing but doesn't develop guidance and believes this should be led by the MCA. They will support actions suggested but this must be led by the MCA with industry input.

Noted (AI summary) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.