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recurance

Paul Rogerson

22 Jan 2014 · Coroner William Coverdale · York

The coroner's concerns

  1. 1. life buoys and throwing lines

    “The position and protection of life buoys and throwing lines is inadequate. Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river. The integrity of this equipment is insufficiently protected from vandalism and the weather.”
  2. 2. lack of warning signs

    “There are no warning signs in place along the river bank within the city walls in York. Only one was found in the course of my enquiry, this being attached to a life buoy harness and being smaller than an A4 piece of paper. Public Houses near the river are not encouraged to display prominent warning signs in areas that their customers have access to the water.”
  3. 3. insufficient training

    “North Yorkshire Police Officers may require further training in current protocols for River Rescue and Water Safety.”
  4. 4. communication gaps

    “North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue.”
  5. 5. lack of hypothermia first aid training

    “North Yorkshire Police officers receive first aid training in CPR and wounds but Hypothermia is currently not covered.”
  6. 6. inadequate buoy condition monitoring

    “There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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