A 30-year-old man from west London died in a jet ski accident while on holiday with his girlfriend in Sierra Leone.
A coroner has now issued a rare 'prevention of future deaths' report following the death of Musa Konteh, warning there were "little or no" safety measures in place where he hired the watercraft.
Mr Konteh, from Hayes, was staying at a beach resort with his girlfriend in Sierra Leone, West Africa, in late March when the tragedy happened.
On Sunday, March 19, he hired a jet ski from the resort, and set out to sea.
An urgent search was launched when he failed to return.
While the jet ski was recovered, Mr Konteh could not be found.
It emerged a passer-by had seen Mr Konteh in the water, but had believed him to be swimming and thought nothing of it.
Mr Konteh's body was found three days later, on March 22.
A north London inquest on November 1 returned a conclusion of 'accidental death'. Mr Konteh's medical cause of death was given as aspyhxia, caused by drowning.
There was no evidence Mr Konteh had consumed alcohol before he took out the jet ski.
Coroner Ian Potter, who presided over the inquest, has since expressed concerns over apparent health and safety failings.
"Little, if any, health and safety procedures were in place for those hiring jet skis," he said in a rare 'prevention of future deaths' report issued this month.
"For example: no instructions on the use of the emergency engine cut-off were given; no instructions were given on any areas to avoid, in the context of an area with many submerged rocks; and no lifejackets were supplied to people hiring jet skis."
Mr Potter also raised concerns regarding travel advice for Sierra Leone, issued by the Foreign, Commonwealth and Development Office (FCDO).
"[It] warns of strong currents and the absence of lifeguards on beaches; however, it does not advise travellers that health and safety standards may be lower than people may experience in UK," he said.
"In my opinion, there is a risk that future deaths could occur unless action is taken," Mr Potter said, in his report issued to the FCDO's Consular Feedback Team.
The FCDO confirmed it had received the coroner's report, and that it would respond in due course.
It added that its travel advice is kept under constant review.