Prevention of Future Deaths reports · 2021

Jordan Mhlanga-Veira

Regulation 28 report to prevent future deaths, reference 2021-0403, written 26 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report26 Nov 2021
Reference2021-0403
DeceasedJordan Mhlanga-Veira
CoronerHeidi Connor
Coroner areaBerkshire
CategoryChild Death (from 2015) · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

             Chief Executive - Environment Agency 

             Seacole, Block 2, 2 Marsham Street, London SW1P 4DF. 

2. 

             Director General - National Trust  

             Heelis, Kemble Drive, Swindon, Wiltshire, SN2 2NA. 

1 

CORONER 

I am Mrs Heidi J. Connor, senior coroner for the coroner area of Berkshire.  

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Reg ulations 2013. 

3 

INVESTIGATION and INQUEST 

I conducted an inquest into the death of Jordan Shaun Mhlanga-Veira at Reading Town 
Hall on 4th November 2021.   

I recorded a conclusion of accident.  

  
  
  
  
 
  
 
  
  
  
  
  
  
  
  
 4 

CIRCUMSTANCES OF THE DEATH 

The f amily asked me to refer to the deceased as Jordan during the inquest.  I will 
respect that wish in this report.  

Jordan was born on 16th August 2005.  31st May 2021 was a hot Bank Holiday Monday, 
and one of the first days on which people were allowed to socialise outdoors after the 
lockdown period.  Jordan, then aged 15, arranged to meet at a site known locally as “

 in Cookham, Berkshire.   

I visited the site, and also heard in evidence that the 

, 

, is shallow and is frequently used by members of the public.  

However, the river depth drops dramatically in the middle of the river.  It would seem that 
Jordan was playing with his friends, and without realising, got into difficulty and 
subsequently drowned in the river.  The evidence showed that one of his friends had 
also got into trouble earlier that day, but had managed to get himself to safety. 

Contrary to popular belief, a drowning person does not always wave and shout.  A 
witness on a boat described seeing Jordan’s head go under the water and sounded the 
alarm.   

Extensive searches were carried out involving numerous emergency services, but 
tragically, Jordan was found dead in the early hours of the following morning.  His cause 
of  death was drowning.    

The National Trust is the landowner for the area in question and gave evidence that it is 
keen to assist in improving safety in this area where possible.  The closest throw rope at 
this scene is approximately 200 metres away.  Tragically, this throw rope was put in 
place f ollowing a similar death of a young teenage boy in 2014.   

The scene of this tragedy is regularly used by many members of the public, effectively 

.  There are no saf ety measures in place at the site.   

We also heard in evidence about the clear difference between tidal and non-tidal waters, 
in saf ety terms. There is currently no statutory framework around safety measures 
applied to inland waters.   

  
  
 
  
  
  
  
  
  
  
 As set out in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) -v- Assistant Coroner 
f or East London, the issuing of a Regulation 28 Report entails no more than the coroner 
bringing some information regarding a public safety concern to the attention of the 
recipient.  The report is not punitive in nature. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

1.  Whilst it is not a matter for the coroner at an inquest to recommend particular 

saf ety measures, I ask that safety measures at the site be reviewed urgently, to 
include consideration of warning signs, position of throw ropes, and 
consideration of buoys in the water (at the point where it becomes deep).   I 
appreciate that many of these measures will contain both advantages and 
disadvantages, and this will be a matter for debate amongst the appropriate 
agencies referred to in this report.  

2.  Consideration should be given to approaching safety in relation to non-tidal 

waters in the same or similar way that tidal waters are dealt with.   Whilst some 
proportionality will of course be required, it may be that there is some 
predictability to areas of particular danger in inland waters, for instance where 
these are regularly used by members of the public (as was the case here), and 
with ref erence to weather, and bank holidays. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 21st January 2022. I, the coroner, may extend the period. 

  
  
  
  
  
  
  
  
  
 Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to Jordan’s family.   

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief  Coroner may publish either or both in a complete or redacted or summary 
f orm. He may send a copy of this report to any person who he believes may find it useful 
or of  interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

I will also send a copy of this report to the Maritime Volunteer Service, Royal National 
Lif eboat Institution and Royal Life Saving Society. 

For the avoidance of doubt, I only require formal responses from the Environment 
Agency and the National Trust.   

9 

26th November 2021 

Mrs Heidi J. Connor 

Senior Coroner for Berkshire

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Enviroment Agency (PDF)
Samantha Perkins 
Secretary to HM Senior Coroner for Berkshire 
Coroner’s Office | Directorate for Economic Growth & 
Neighbourhood Services 
Reading Borough Council 
Reading Town Hall 
Blagrave Street 
Reading  
RG1 1QH 
Sent via email 

Date: 24 January 2022 

Dear Samantha, 

Environment Agency Response to Regulation 28 Coroners (Investigations) 

Regulations 2013 Report following the Inquest into the death of Jordan Shaun 

Mhlanga-Veira at Reading Town Hall on 4th November 2021  

On behalf of the Environment Agency, and particularly those staff involved in the 

Inquest and the writing of this response, I would like to send our sincere condolences 

to Jordan’s family at this tragic time.   

I address the following Matters of Concern that you asked us to consider–   

Matter of concern 1. 

Whilst it is not a matter for the coroner at an inquest 

to recommend particular safety measures, I ask that safety measures at the 

site be reviewed urgently, to include consideration of warning signs, position 

of throw ropes, and consideration of buoys in the water (at the point where it 

becomes deep).   I appreciate that many of these measures will contain both 

advantages and disadvantages, and this will be a matter for debate amongst 

the appropriate agencies1 referred to in this report.  

1. Our response has been prepared following discussions with the National

Trust.  The National Trust is the landowner at Cockmarsh Field, Cookham and

Chief Executive’s Office, Environment Agency 
Seacole Block, 2 Marsham Street, London, SW1P 4DF 

http://www.gov.uk/environment-agency 

  
 therefore controls the access point by which members of the public are able to 

enter the Thames from ‘the beach’ at the location in question.  As such, the 

National Trust has health and safety responsibilities towards those persons, 

which may include warning signs and rescue devices based upon risk 

assessment.   

2.  The Environment Agency is the navigation authority for the River Thames, the 

Medway, the River Wye and for Anglian Waterways (Ouse, Nene and Stour).  

We are also harbour authority for Rye Harbour.   Our primary function as a 

navigation authority is the regulation of the waterways in accordance with the 

applicable legislation. 

3.  For the purposes of this response, we concentrate on our responsibilities in 

relation to the River Thames.  The Environment Agency is the navigation 

authority for the whole of the non-tidal part of the Thames, ending at the tidal 

boundary at Teddington Lock, at which point the navigation authority becomes 

the Port of London Authority.  The main navigation powers for the Thames are 

set out in the Thames Conservancy Acts 1932-1966 (‘TCA’), and in the 

Thames Navigation Licensing and General Byelaws 1993 (‘the Byelaws’) 

which are made under the TCA.  Also of relevance is the Inland Waterways 

(Environment Agency) Order 2010, an overarching piece of legislation 

covering Thames, Medway and Anglian waterways.  

4.  As navigation authority for the Thames, we have a duty to manage water 

levels (s73 and s76 TCA).  We also have various powers (but no duty) to 

remove obstructions in various places along the Thames (s104-107 TCA) to 

ensure navigation is not interrupted.   

5.  Under Byelaw 63(b) it is an offence to bathe in the Thames where the 

Environment Agency has put up a sign forbidding it.  However, our powers to 

erect a sign in our capacity as navigation authority are limited to 

circumstances connected to navigation itself, not recreation. For example, 

under Byelaw 63(b), we could erect a sign to prohibit swimming in order to 

prevent interference with the public right to navigate the Thames, but not to 

prohibit swimming generally.  

 
 
 
 
 
 
 
   
 
 
 6.  Similarly, the Environment Agency has limited powers to cordon off sections 

of the Thames.  We may restrict the general public’s right of navigation, under 

section 79 of the TCA for purposes connected with maintaining a navigable 

waterway - for example, in order to carry out repairs to locks or weirs.  

However, we do not have the power to cordon off an area of river to create a 

swimming area.  In any case, we would be reluctant to cordon off sections of 

the river as it could be seen as an encouragement to swim, suggesting the 

area is safe for swimming. 

7.  We are not generally the riparian owner of the bed of the river Thames and so 

our ability to place buoys or other items connected the riverbed are bound by 

our navigation powers, not influenced by our ownership of the riverbed.  We 

are not the riparian owner of the section of riverbed next to Cockmarsh Field. 

8.  In relation to health and safety, there is a duty placed on the navigation 

authority under the Health and Safety at Work Act 1974 to (within the 

parameters of its powers and duties as navigation authority), ensure that 

those that navigate the waterway are not exposed to risks to their health and 

safety ‘so far as it is reasonably practicable’.  Every vessel navigating the 

Thames must be navigated with care and caution and at such speed and in 

such manner as not to endanger the lives or cause injury to others (s97 TCA). 

9.  It is part of the Environment Agency’s general obligations with respect to 

water “generally to promote”, “to such extent as it thinks desirable”, “the use of 

waters and land for recreational purposes”.  This duty to promote recreation 

must be consistent with the Environment Agency’s duties under the law, for 

example, consistent with the duties of a navigation authority to maintain the 

public right of passage along the river (s7(4) Environment Act 1995) and our 

duties under the Health and safety at Work etc. Act 1974 (‘the HSW Act’).    

10. For the reasons stated above, the Environment Agency has very limited 

capacity to introduce safety measures in relation to swimmers entering the 

water at Cockmarsh Field.  

11. The Environment Agency nevertheless takes very seriously the matter of 

water safety in relation to its land and assets.  We are a member of the 

National Water Safety Forum, which is hosted by the Royal Society for the 

 
 
 
 
 
 
 
 
 
 
 Prevention of Accidents (‘RoSPA’) and supported by the Royal Life Saving 

Society UK (‘RLSS UK’).  We support and follow its published guidance, 

‘Managing Safety in Inland Water Sites’ 

https://www.flipsnack.com/rospacatalogue/rospa-managing-safety-at-inland-

waters.html , guidance which was drawn to the attention of the Coroner, by 

, during Jordan’s inquest.  The guidance provides valuable 

advice for those in control of sites where members of the public have access 

to water.   

12. We publish advice for the public on how to stay safe while visiting waterways: 

www.gov.uk/government/publications/staying-safe-around-water .  We run 

information campaigns to raise awareness of water safety around our assets 

and landholdings.  We focus our attention on those assets which are known to 

be popular swimming or canoeing spots, for example, Teddington Lock.   For 

example, in June 2021, in partnership with local representatives of other 

agencies with water safety roles and responsibilities on the river Thames – 

Royal Berkshire Fire and Rescue Service, Thames Valley Police, Royal 

Borough of Windsor and Maidenhead Council – we carried out a patrol in the 

Boulters Lock and Ray Mill island areas of Maidenhead, engaging with 

members of the public about the risks posed by swimming in the Thames and 

other waterbodies. 

13. The Environment Agency is also an active member of the HSE approved 

Visitor Safety Group https://www.visitorsafety.group/,  which also works in this 

area of public safety.  Other members of the group include the National Trust 

and British Waterways. 

14. The Environment Agency will continue to work with the National Trust so far 

as our powers and duties as a navigation authority allow, to ensure the safety 

of the public visiting the Thames.  

Matter of concern 2.  Consideration should be given to approaching safety in 

relation to non-tidal waters in the same or similar way that tidal waters are 

dealt with.   Whilst some proportionality will of course be required, it may be 

that there is some predictability to areas of particular danger in inland waters, 

 
 
 
 
 
 
 
 
 
 
 for instance where these are regularly used by members of the public (as was 

the case here), and with reference to weather, and bank holidays. 

1.  We note the Coroner’s comment that there is ‘currently no statutory 

framework around safety measures applied to inland waters’ and we do not 

feel that this is the case.  There is established legislation and case law 

concerning public safety, which applies to all waters, both tidal and non-tidal.    

2.  The Environment Agency is responsible for safety on waterside assets it 

owns, operates or occupies (such as locks, weirs and bridges).  In the case of 

Cockmarsh Field, the scope of our role is as navigation authority for the 

stretch of river.  We do not own or occupy the land and have no assets 

positioned there. 

3.  Under criminal law (the HSW Act and associated regulations) employers are 

under a duty to ensure, so far as is reasonably practicable, that in the course 

of carrying out their undertaking (their work), members of the public are not 

put at risk. This includes the management of land and assets that are owned 

or occupied by that employer.   Specifically, section 3(1) of the HSW Act 

establishes a duty on an employer to -  

‘conduct his undertaking in such a way, so far as is reasonably practicable, 

that persons not in his employment who may be affected thereby are not 

thereby exposed to risks to their health and safety’.  

4.  Where the Environment Agency owns or occupies a site and it therefore forms 

part of our undertaking, we are under a duty to assess the risks our assets 

and landholdings pose.  We do this by carrying out a public safety risk 

assessment which identifies measures to take to reduce risk to its staff and to 

the public.  The risk assessment will address factors such as popularity of use 

and the factors which influence that popularity, such as weather and bank 

holidays. It will also take into account factors that may be influenced by the 

tidal or non-tidal nature of the water body. Taking all relevant factors into 

account, we then take all steps that are reasonably practicable and that we 

are empowered to take, to reduce and control those identified risks.  

Reasonable steps might include, for example, putting up warning signs on a 

weir to warn against or inform of the risks to swimming or canoeing.   We 

continue to inspect regularly those assets to ensure the provided risk control 

 
 
 
 
 
 
 
 
 measures are well maintained and remain appropriate. Depending on the 

levels of risk associated with a particular asset, we also review our public 

safety risk assessments at suitable intervals.  

5.  In addition to our duties under the HSW Act, under civil law the occupier of 

land or an asset has responsibilities under the Occupiers Liability Acts of 1957 

and 1984 (‘the Acts’) to ensure the safety of visitors and the uninvited to those 

premises. The Environment Agency adopts a wide definition of ‘occupier’ and 

‘occupation’; if we are responsible for the maintenance of an asset, or if we 

are the landholder (subject to any lease or licence) we arguably have 

sufficient control of the area to fall within the remit of ‘occupier’.  As such, we 

may have a duty under the Acts to take reasonable steps to keep people 

visiting the area safe and/or to ensure they do not suffer injury on the 

premises by reason of the danger concerned.   

6.  There is a large body of case law which considers the balance between 

responsibilities of owner/occupiers of land and those of persons entering upon 

land to undertake, in some cases, dangerous activities.  I refer the Coroner to 

Tomlinson v Congleton Borough Council and Others 31 July 2003, Staples v 

West Dorset Council 1995 and Duff V East Dunbartonshire Council and 

Others [1999].   The case law points to an approach towards safety, whereby 

people take on a degree of responsibility for their own actions when carrying 

out potentially dangerous activities.   

7.  We note the Coroner’s comment that further consideration should be given to 

developing water safety.  Policy decisions on the matter of inland and coastal 

water safety are the responsibility of central government, including the 

Cabinet Office and the Department for Environment, Food and Rural Affairs. 

Yours sincerely 

Chief Executive
Response from National Trust (PDF)
- OFFICIAL - Regulation 28 to Prevent Future 

Deaths - The Late Mhlanga-Veira 

Date: 21 January 2022 

Mrs Heidi J Connor 

Senior Coroner for Berkshire 

Sent via Email only 

Response to Regulation 28 PFD Report from the National Trust 

1. The  National  Trust  (“The  Trust”)  is  a  registered  charity  incorporated  by  statute.  It  is  a
membership organisation and works to preserve places of historical interest and natural beauty
in England, Wales, and Northern Ireland. The Trust facilitates access to such places for the
benefit of the nation.

2. We would once again like to express our sincere condolences to Jordan`s family and friends.

3. The Trust was not an Interested Person to the inquest touching on Jordan’s death and did not
receive  disclosure  in  advance  of  the  inquest.  However,  to  assist  HMSC,  the  Trust  provided
statements  from 

,  Operational  Senior  Risk  Business  Partner  and 

, General Manager for the Cliveden portfolio, which includes the area of the Thames at
Cock  Marsh  where  the  accident  occurred.  These  statements  set  out  details  of  the  Trust’s
approach to water safety on the land it owns along the coastline and near inland waterways
and details of the specific risk assessment and control measures in place at Cock Marsh. Both
statements were admitted in evidence under rule 23.

4. HMSC requested the attendance of a witness from the Trust to assist in her consideration of
Regulation  28  issues,  specifically  with  regards  to  signage  and  water  safety  issues  at  Cock
Marsh.

5. This response to the Regulation 28 report should be read with the statements of 

and 

.

6. As a responsible landowner with many miles of coastline and waterways, the Trust takes its
responsibilities  very  seriously  including  the  safety  and  wellbeing  of  visitors.  The  Trust  is  a
longstanding member of the Visitor Safety Group (VSG) a partnership organisation concerned
with visitor safety. Other members of the group include British Waterways and the Environment
Agency.    The  Trust  adopts  the  VGS’s  guiding  principles  that  emphasise  the  importance  of
conservation,  access  and  personal  enjoyment  of  the  countryside  and  need  to  find  balance
between safety and its wider objectives. The principles also underpin the balance between the
personal responsibility of visitors and responsibility of the landowner.

 
  
 7. 

In this response, The Trust addresses the  2  areas  of concern set out  in paragraph 5 of the 
Regulation 28 report. The responses follow discussions with the Environment Agency. 

8.  The Trust also outlines below the main legal duties and case law relating to water safety risks 

and the issues relating to the land at Cock Marsh.  

9.  HMSC heard evidence from 

 as part of her consideration for making a Regulation 
28 report. 
 gave evidence (also contained in his statement) that the Trust owns parts 
of the land known as Maidenhead and Cookham Common. Cock Marsh forms part of that area. 
The land at Cock Marsh is registered as Common under the Common Land Registry. The Trust 
has a specific statutory duty to keep common land unenclosed and unbuilt on as open spaces 
for  the  recreation  and  enjoyment  of  the  public.  It  is  not  within  the  power  of  the  Trust  as 
landowner  to  fence  or  obstruct  the  public  or  commoner’s  access  to  the  area.  The  Trust  as 
landowner  must  take  account  of  commoner’s  rights  while  managing  common  land.  It  is  not 
possible, practicable or desirable to restrict public access to the river in this area of land.    

10.  A landowner of one side of the bank of the river, may have riparian ownership of the riverbed 
to the middle of the watercourse where generally the ownership would transfer to the opposing 
bank  landowner  a  full  review  of  title  deeds  of  any  landowners  would  be  needed  in  order  to 
ascertain  the  riverbed  ownership  at  any  particular  point.    The  Trust  understands  the 
Environment  Agency  is  the  authority  with  specific  powers  and  duties  in  relation  to  the  River 
Thames and navigation at this location.  

11.  The Regulation 28 report refers to evidence heard at the inquest about the differences between 
 from 
tidal and non-tidal waters in terms of safety. HMSC heard evidence from 
the Kingston Marine Volunteer Service and 
 from the Environment Agency that 
suggested there were differences between coastal waters and inland waterways in terms of 
safety arrangements.  

The Legal Framework and Relevant Guidance 

12.  The  relevant  statutory  and  common  law  provisions  apply  equally  to  coastal  and  inland 
waterways. The applicable law for landowners can be found within the Occupiers’ Liability Acts 
and for employers, the Health and Safety at Work etc. Act 1974. Neither of the statutes impose 
a duty on the landowner to guard against an obvious hazard such as a water course or provide 
risk  mitigation  measures  for  those  who  choose  to  undertake  activity  not  being  promoted  or 
organised  by  the  landowner  or  employer’s  undertaking.    The  application  of  these  statutory 
provisions and of the common law has been clearly and authoritatively stated by the High Court, 
Court of Appeal and the House of Lords. 

13.  In Darby v National Trust [2001] PIQR P372 the claimant's husband was tragically  drowned 
while swimming in a pond on the National Trust estate at Hardwick Hall. The pond was owned 
by the National Trust. At trial there was uncontradicted evidence which the judge accepted that 
the pond was unsuitable for swimming because it was deep in the middle and the edges were 
uneven. It was submitted that the National Trust should have made it clear that swimming in 
the pond was not allowed and taken steps to enforce the prohibition. Allowing the appeal of the 
National  Trust  May  LJ  giving  the  judgment  of  the  court  of  appeal  rejected  that  submission 
(emphasis added): 

“27. [Counsel for the claimant] submitted that there was no proper correlation between 
the risk of swimming in this pond and the risk of swimming in the sea or other open 
water. I do not agree. It cannot be the duty of the owner of every stretch of coastline to 
have notices warning of the dangers of swimming in the sea. If it were so, the coast would 
have to  be  littered with notices in places  other than  those where there are known to be 
special  dangers  which  are  not  obvious.  The  same  would  apply  to  all  inland  lakes  and 
reservoirs. In my judgment there was no duty on the National Trust on the facts of 
this  case  to  warn  against  swimming  in  this  pond  where  the  dangers  of  drowning 
were no other or greater than those which were quite obvious to any adult such as 
the unfortunate deceased. That, in my view, applies as much to the risk that a swimmer 

 
 
 
 
 
 
 
 
 
 might get into difficulties from the temperature of the water as to the risk that he might get 
into difficulties from mud or sludge on the bottom of the pond.” 

Darby was cited with approval by the House of Lords in Tomlinson v Congleton Borough 
Council [2004] AC 46. There was debate about whether the claimant in that case was a 
trespasser, but the case did not turn on that factor. The claimant ignored warning signs and 
dived  into  a  lake  that  had  formed  in  a  disused  quarry  owned  and  managed  by  the 
defendants. He suffered grave injury. His claim for breach of statutory duty and at common 
law failed. The reasons included that the risk was attributable to the conduct of the claimant, 
not the state of the premises (paragraphs 27 and 34) and the following (emphasis added): 

“Free will” 

44.  The  second  consideration,  namely  the  question  of  whether  people  should  accept 
responsibility for the risks they choose to run, is the point made by Lord Phillips of Worth 
Matravers MR in Donoghue v Folkestone Properties Ltd [2003] QB 1008, 1024, para 53 
and  which I said was central to this  appeal.  Mr Tomlinson was freely and voluntarily 
undertaking an activity which inherently involved some risk…  

45.  I  think  it  will  be  extremely  rare  for  an  occupier  of  land  to  be  under  a  duty  to 
prevent  people  from  taking  risks  which  are  inherent  in  the  activities  they  freely 
choose to undertake upon the land. If people want to climb mountains, go hang-gliding 
or swim or dive in ponds or lakes, that is their affair. Of course the landowner may for his 
own  reasons  wish  to  prohibit  such  activities.  He  may  think  that  they  are  a  danger  or 
inconvenience to himself or others. Or he may take a paternalist view and prefer people 
not to undertake risky activities on his land. He is entitled to impose such conditions, as the 
Council did by prohibiting swimming. But the law does not require him to do so. 

Further, Lord Hutton stated: 

“59. … it is contrary to common sense, and therefore to sound law, to expect an occupier 
to provide protection against an obvious danger on his land arising from natural features 
such as a lake or a cliff and to impose a duty on him to do so …” 

14.  The same considerations apply to the duty under the Health and Safety at Work Act 1974 and 
associated Regulations such as the Management of Health and Safety at Work Regulations 
1999,  see  R  (Hampstead  Heath  Winter  Swimming  Club)  v  Corporation  of    London  [2005]  1 
WLR 2930.   

15.  Relevant guidance to landowners such as the National Trust is to be found in Managing Visitor 
Safety in the Countryside, now in its third edition. This is produced by the Visitor Safety Group, 
comprised of a number of organisations that own and manage land and property with day-to-
day  experience  of  visitor  management  as  well  as  the  national  policy  makers  and  specialist 
safety advisors. The guidance is endorsed by the Health and Safety Executive in the following 
terms: 

“The HSE supports the VSG’s commitment to promoting a sensible and proportionate 
approach to managing safety in the countryside. The guidance provides a valuable framework 
for managing risk to visitors which is sensitive to the intrinsic value of the landscape and does 
not unduly restrict public access”  

16.  The  Trust  applies  the  VSG  guiding  principles  through  its  process  of  site-specific  risk 
assessments.  In  particular,  the  Trust  aims  to  take  account  of  conservation,  heritage, 
recreational and cultural landscape objectives and aims to avoid taking away people’s sense 
of freedom and adventure. This approach also balances the individual’s free choice with the 
suitability and practicability of any risk reduction measures while not curtailing the freedoms of 
all.  

 
 
 
 
 
 
 
 
 
 
 
 
 Prevention of Future Death Report 

17.  The Senior Coroner has set out two matters of concern. 

18.  The first of these concerns relate to safety measures specifically in relation to Cock Marsh. The 
second  area  of  concern  relates  to  inland  waters  more  generally  with  consideration  to 
approaching safety in relation to non-tidal waters in the same way that tidal waters are dealt 
with.  

19.  At Cock Marsh, the Trust produced a detailed risk assessment for a large area of open common 
land  with  multiple  points  of  entry.  This  included  the  access  to  the  River  Thames.  The  Trust 
neither owns nor has control of the River Thames. The Trust does not prohibit or promote or 
encourage swimming.   

20.  The Thames itself is an obvious water course with a marina opposite and boats and watercraft 
of various sizes operating throughout the day. The water must be of sufficient depth for boats 
to use the river. In addition to the risk of drowning there is the additional hazard of moving craft. 
Both risks are plain and obvious. 

21.  As a landowner with extensive ownership of inland waterways and coastal areas and with many 
millions of visitors a year, it is not reasonable or practicable to patrol all areas where visitors 
may choose to take risks at any time of the day. There is no requirement for landowners to 
safeguard all possible risks that visitors choose to undertake including entry into the water.  

22.  Following discussions with the Environment Agency, the Trust acknowledges that stretches of 
the Thames can become deep suddenly, and that water visibility is generally insufficient to the 
depth of hazard beneath the surface, and it can be difficult to establish the speed of the flow. 
All these factors can be influenced by meteorological events including the amount of rain further 
upstream  which  make  hazards  variable  in  nature.    This  further  detailed  information  will  be 
considered in the risk assessment. 

23.  The Trust is very grateful to the Senior Coroner both for her suggestions and her recognition 
that there are competing considerations which do not lend themselves to clear or easy answers. 

24.  Buoys.  The  Trust  does  not  own,  operate  or  control  the    River.  It  is  not  within  its  power  to 
unilaterally  place  buoys  in  the  water.  However,  even  if  it  was,  the  Trust  would  have  a  very 
serious concern that the presence of buoys would indicate by implication that areas of the River 
were safe to swim in and thereby encourage people into the water. That would be contrary to 
the Trust’s overall approach to water safety and the relevant guidance. Further, buoys would, 
as the Trust understands it, interfere with the legitimate rights of users of the river. The Trust 
understands this is also the position of the Environment Agency. 

25.  The  position  of  throw  ropes.  The  Trust  does  not  generally  provide  throw  ropes.  It  does  not 
believe the specific rope referred to was located on National Trust land. Experience tells us that 
equipment such as throw ropes is often stolen and/or vandalised. The Trust’s experience is that 
the  provision  of  public  rescue  equipment  creates  an  inducement  for  either  misuse  or  a 
perception of safety. 

26.  Signage. The Trust and the Environment Agency have concerns around the effectiveness of 
signage measures and its environmental impact. That is especially so where, as here, there 
are multiple routes to the water.   

27.  Nevertheless, the public access risk assessment covering Maidenhead and Cookham Common 

including  Cock  Marsh  was  reviewed  by  the  Operational  Risk  Business  Partner 

 as soon as the Trust was made aware of the incident. Following the conclusion of the 
inquest, an urgent review was undertaken whether the site posed any specific extra risk at that 
time. The Trust’s Legal and Operational risk team discussed and considered the matter and 
concluded that factors such as the time of year and weather meant that the site was unlikely to 
be at any increased risk at that time.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 28.  Following  your  report,  it  was  agreed  as  a  priority  the  General  Manager 
 and Head of Compliance 

,  Lead 
Ranger, 
 would visit the site and review 
the current risk assessment and consider whether further reasonably practicable and effective 
measures could be put in place to reduce the risk associated voluntarily accepted by those who 
chose to swim in that area of the Thames.   

29.  The risk assessment was reviewed fully during the site visit in January 2022. It is anticipated 

the following steps will be implemented:      

i) 

ii) 

iii) 

Following the site visit and review of the current visitor risk assessment, which covers 
a large area of land and a number of other visitor risks,  the area known as the beach 
and other potential similar locations at Cock Marsh will be separately drawn out into a 
distinct visitor risk assessment specially to consider drowning risk.  

This new  risk assessment  document will provide a fuller description  of the area  and 
further  details  of  control  measures  already  in  place  together  with  reasoned 
consideration for the approach to any hazards that are not obvious.  

A signage pilot will commence prior to the early spring Bank Holiday to test the location, 
wording and effectiveness of such measures at the specific location warning of depth, 
strong  currents,  and  hidden  obstacles.  The  risk  assessment  will  also  consider  the 
location of existing lifesaving equipment and whether further provision should be made. 

30.  There are plans for the Property Team to share this information Jordan`s family.   The Trust 
would  also  propose  reviewing  website  visitor  information  and  content  for  this  property  to 
consider reflecting any additional information informed by the risk assessment  / signage pilot. 

31. The  Trust  has  carefully  considered  the  second  matter  of  concern  within  the  Regulation  28 
report. For the reasons set out above the Trust does not believe there is any legal distinction 
between  non-tidal  and  tidal  waters  or  coastal  or  inland  waterways.  As  such,  the  same  legal 
duties apply to both coastal waters and inland waterways and tidal and non-tidal waters. The 
Trust does not make any specific distinction between coastal waters and inland waterways as 
far  as  water  safety  is  concerned  and  undertakes  risk  assessments  with  annual  reviews  that 
consider visitor safety on the land it owns along the coastline and next to inland waterways. In 
both cases it applies the VSG Guidance.   

32.  It remains the view  of the  Trust that the  best control  mechanism for  the risks associated with 
Coastal  and  Inland  Waterways  and  tidal  and  non-tidal  water  courses  is  better  education.  The 
Trust  recently  contributed  the  National  Water  Safety  Forum  consultation  on  improving  water 
safety and noted with interest at the recent conference the planned adoption of new water safety 
messaging and campaigns for 2022.  

Assistant Director. 

Cc. Director General’s Office for National Trust.

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