Prevention of Future Deaths reports · 2014

Benjamin James Carroll

Regulation 28 report to prevent future deaths, reference 2014-0068, written 20 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Feb 2014
Reference2014-0068
DeceasedBenjamin James Carroll
CoronerWendy James
Coroner areaGwent
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT !S BEING SENT TO:
Ms Anne Adams-King

Chief Executive Officer, Welsh Cycling, Wales National Velodrome,
Newport International Village, Newport. NP19 4RB

1 | CORONER

1 am Wendy Ann James, assistant coroner, for the coroner area of Gwent

2 | CORONER'S LEGAL POWERS

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

3 | INVESTIGATION and INQUEST

On 15" July 2013 | commenced an investigation into the death of Benjamin James
Carroll (d.o.b. 10-12-86). The investigation concluded at the end of the inquest on 13-
02-14. The conclusion of the inquest was accidental death. The medical cause of death
being:-

1. (a) Multiple Injuries

4 | CIRCUMSTANCES OF THE DEATH

On 09-07-13 Mr. Carroll was taking part in the stival Handicap an open
toad cycle event along the B4598, organised b: f the Abergavenny Road
Ciub. Whilst sprinting to the finish line Mr. Carroll and a number of other cyclists,

crossed the white line, in to the opposite carriageway. Mr. Carroll's cycle collided with
an oncoming van and he sustained injuries from which he later died.

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 will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —
As the cyclists grouped together and sprinted towards the finish line, the road remained

open to traffic despite the presence of accredited marshals with powers to stop/direct
Traffic.

6 | ACTION SHOULD BE TAKEN

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

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16" April 2044. |, 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.

COPIES and PUBLICATION

Ihave e Chief Coroner and to the following Interested
Person

lam 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
form. 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.

[DATE] [SIGNED BY CORONER]

20-02-14 WA Jane .

Responses

1 response 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 Welsh Cycling (PDF)
Ui
. BEICIO CYMRU
WELSH CYCLING

Wales National Velodrome
Newport International Sports Village

Newport
01 April 2014 NP19 4RB

T: 01633 283979
Wendy James 02 APR 2014 F: 01633 277116

Coroner's Office E: info@welsheycling.co.uk

Victoria Chambers www.welshcycting.co.uk
414 Clytha Park Road

Newport, Gwent

NP20 4PB

Dear Ms James,
Ref: Benjamin James Carroll

First, we wish to reiterate our sympathies with the family and friends of Ben Carroll and with all those
affected by his death and are grateful for this opportunity to respond to the Coroner's request.

Welsh Cycling is the national governing body for cycle sport in Wales and all cycling competition in
Great Britain is regulated by British Cycling (The British Cycling Federation). It is important to note,
therefore, that Welsh Cycling cannot unilaterally change the rules and regulations of the sport
without the agreement of British Cycling and its constituents.

The safety of riders in events is, of course, of paramount importance to Welsh Cycling and the
cycling community is greatly affected when a tragedy such as this occurs.

Every effort is taken to ensure the safety of riders at all events and, indeed, all racing on public roads
has been stringently regulated for over 50 years, since the introduction of the 1960 Cycie Racing on
the Highway Regulations, ensuring that all races are:

. Authorised by the retevant police force;
° Organised to a consistently high standard with appropriate safety measures in place
° Delivered under standard highway conditions

Prier to-all British Cycling / Welsh-Cycling events, all_participants, including riders, officials, and
support staff, are reminded of the conditions that the race is held under, including highlighting the
risks associated with the event. All participants are reminded that events are held under standard
highway conditions, that accredited marshals are only permitted to stop and hold traffic for short
durations, typically at junctions, and that there will be oncoming traffic.

It is important to note, therefore, that accredited marshals are not empowered to suspend standard
highway conditions or enforce any kind of road closure, at any point on the course, including race
finishes

Such measures, taken to ensure the safety of our competitors, are not limited to officiating on the
day, but also involve continuous training and education of officials through a range of interventions
which takes place throughout the year.

As a result of the afore-mentioned regulation, preventative measures and training, fatalities are
thankfully rare in cycle sport.
ed G Atnnancan vtoreet S@lIEE-

‘Wed gofrestra yn Uoegr a Chymru ei Unde Beco Cynru Cyfyngedig rf 4954973 | Repitered In Grland and Wales as Welsh Cycling Union Limited no: 4834971,
Reglsered Address fo Wats Gregary LIP Fifed House, Cak Tree Cour. Mutberry Drive. Cara? Gate husimess Prk, Cara CFZ3 ERS

Working with British Cycling we are, however, continually monitoring the safety of the sport in this
country. We have a programme of training and education for our event officials, from courses to
online resources, and we are continuously working to enhance key elements. In recent years we
have developed and delivered a series of officials’ conferences that have included dedicated risk
management workshops in response to incidents and identified areas of risk.

In light of the recent tragic death of Ben and given the desire of more people to get active through
competitive cycle sport, we are in the process of implementing a further significant and more
widespread programme of training, education and publicity to continue to ensure that all participants
are aware of the conditions and regulations under which racing is held and the need to race safely
and responsibly.

More specifically we will be launching an awareness campaign called ‘racesmart’. The campaign wil
primarily target participants, but it will also support event organisers and officials in their voluntary
roles, to ensure the safe running of all events. Racesmart will carry consistent core messages
focussing on safety and responsibility. Targeted activity will range from direct communication to
participants via British Cycling’s online entry system, through to the development of educational
digital content and @ managed social media campaign. a ~ —

We trust that this combination of measures will continue to minimise the risks for riders and other
Toad users.

Yours sincerely

Q&.08 Oclowws eang

Anne Adams-King

Chief Executive Officer] Pri _ Gweithredol

on WOME ERIE

‘Wea gotrestra yn Lloegr a Chymru fel Unde Becio Cymru Cyfyngedig rit: 6350971 | Repstered in kogland and Wales as Wels Cycing Union Limlks¢ wo: 8354972
Raptreres adcress: fo Wats Gregory LP Elfed House, Oak Tree Court, Mulberry Urve, Caaf Gate Business Pak, Cardi CF23 BRS

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