Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0371, written 12 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2014 |
|---|---|
| Reference | 2014-0371 |
| Deceased | Dylan Rattray |
| Coroner | Nicola Jones |
| Coroner area | North West Wales |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
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 IS BEING SENT TO:
1. CHIEF EXECUTIVE SNOWDONIA NATIONAL PARK AUTHORITY
1
CORONER
I am Nicola Jones assistant coroner, for the coroner area of North West Wales
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) Regulations 2013.
3
INVESTIGATION and INQUEST
4
On 22 April 2014 I commenced an investigation into the death of Dylan Arwel Rattray
aged 21 years. The investigation concluded at the end of the inquest on 30 July 2014.
The conclusion of the inquest was that the medical cause of death was 1a Multiple
Injuries 1b. Consistent with a fall from a height
CIRCUMSTANCES OF THE DEATH
The deceased was a fit and healthy young man who walked to the summit of
Snowdon along the challenging route of Crib Goch with his friend who was of
similar fitness. Neither were particularly experienced mountaineers. Their
footwear was unsuitable to areas off the paths. It was their plan to stick to the
paths on Snowdon they did not carry maps or guide books and were therefore
heavily reliant upon the paths.
The pair decided to descend from the summit using what appeared to be an
established path heading down towards Glaslyn. This covers an area known as
Clogwyn Y Garnedd. After walking for 30 minutes the path petered out and the
pair found themselves on loose scree. The deceased decided to press on as the
pair realised that it was impossible to return the way they had descended due to
the terrain. Moments later the deceased fell some 200 metres sustaining fatal
injuries.
The surviving friend was left in a perilous position on the mountain and was
rescued thanks to the joint efforts of the RAF search and Rescue Helicopter and
Llanberis Mountain Rescue Team whose lives were also at risk due to the terrain.
The deceased was recovered by the SAR helicopter but prior to the arrival of the
helicopter some nearby walkers ( medical students) left the PYG track to attempt
to assist the deceased. Their lives were also endangered by this act. The friend
of the deceased gave evidence that the pair would never have taken the
descending route had they known that this was not a continuous and established
path.
At Inquest Mr
gave evidence that there have been multiple casualties and rescues on Snowdon
due to walkers using paths which appear to be established and continuous paths
down /up the mountain but eventually peter out leaving walkers in life threatening
situations. In April 2012 a walker died in similar circumstances to the deceased.
He stated that on three occasions the LMRT have written to the Park Authority and
the Chairman of Llanberis Mountain Rescue Team
1
have requested that the Park Authority give serious consideration to breaking up
these paths to prevent further serious injury and loss to life, not just to walkers
but also to rescuers. He stated that LMRT did not feel sign posting alone would
provide the necessary safeguards.
changes to the definitive lines near the Summit of Snowdon in particular at The
Watkin Path and The Cwellyn , together with work to diminish paths which appear
established but peter out. The Snowdonia national Park did not follow the advice
but invested in signposting. On the day of the Inquest another walker fell to his
death in the same location of the deceased
CORONER’S CONCERNS
in particular requested minor
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. –
(1) Whilst it is acknowledged that Snowdon is an inherently dangerous terrain which
attracts millions of walkers of all abilities every year without incident in most
cases, I am concerned that the Snowdonia National Park Authority have
chosen not to follow the advice of an organisation such as the Llanberis
Mountain Rescue Team which has been given in writing on two occasions
detailing how the risk of future deaths and serious injury could be reduced.
(2) The deceased in this Inquest was a sensible , fit , hardworking young man, not a
foolhardy risk- taker. He followed what he thought was an established path that
would take him down to Glaslyn. Had the Park taken the previous advice of the
Llanberis Mountain Rescue team to break up these misleading paths then this
death would not have occurred as the deceased would not have attempted to
descend the route which he took, which led to his death
(3) It is acknowledged that the Park not only has to consider budgetary constraints
but also the difficult and dangerous terrain where improvement works would be
required. However, unless robust and permanent measures are taken to ensure
that walkers cannot access what they believe to be established paths at the
Summit of Snowdon ( thereby providing a mistaken sense of security ) when
such paths peter out and leave walkers in perilous positions, then I am satisfied
that there will be repeated deaths in these circumstances on Snowdon .
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 7 October 2014. 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 the following Interested
Persons,
father of deceased.
witness.
Chairman Llanberis Mountain Rescue Team. Chief Constable, North Wales
Police. Senior Officer , RAF 22 Squadron, Valley, Anglesey. Chief Executive, Cyngor
Gwynedd , who may find it useful or of interest.
2
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
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.
9
[DATE] 12/08/14 Nicola Jones
3
Map A: Overview 261000 262000 263000 id ; ca Y An >. th ; e ae oe: oe toys Carreg.Gwalchs, ~ ‘or Grey Cliffs | Ze Grey cits Stl ee pant Van yr ie Horns Sieh! f 9a ol 3 ete gel» Ie 8 \ ye yh. f °* Liyrttydaw'tResr) "he : Mts <eraig Lyn 7 |p z bet ee ae g ° ESTE "y) ee 48 a) “ae tee Clogwyn Pen > ps ath “ee” 45 Rey 4g. . > te of oh ws. Uechen 7 a, me <a, ae 1) Gye r ba Miners Track’ ° @ sm GSI in es Hafod Eryri Ke Gf y ‘on 3 é Cwm Dyli : Mecca al > i f a ad Sheepfold : the Dns DANY od cs . ‘ 1; Bn. f se (i) . : a ‘ ‘i i : . ‘ 4° .€raig Aderyn or Teyrn Slab. Sheepfold : dis) 3 sheepfo| = (dis) 4m 354000 O00rSE 261000 262000 F f . i © Hawlfraint y Goton a hawli fa ddata / =<=—= Bridleway Likely route by Lluniwyd Gan /'Compiled By: L.l (GIS Officer) G Crown copyrightand database rights Awdurdod Parc Cenedlaethol Eryri ==== Footpath © © _ Dylan Rattray and Jac Bonner Land owned by SNPA Dyddiad / Date: 25/09/2014 2014, Ordnance Survey 100022403 Snowdonia National Park Authority if rid inet 1 Swyddfa'r Parc Cenedlaethol ~ National Park Office Crib Goch desire line F ' Hawlfraint Awdurdod Pare Cenedlaethol Eryri Penrhyndeudraeth = fe ons possible line taken by C_] Inset Maps B & C . Copyright Snowdonia National Park Authority Gwynedd East Ridge desire line @ @ @ Dylan Rattray and Jac Bonner Graddfa / Scale 1:10000 et GH 01766770274 LL48 6LF
Map B: Inset Map with aerial photography captured in 2013 ~®\ Directional pillars — Eastridge desire line Likely route taken by Lluniwyd Gan / Compiled By: LJ (GIS Officer) Dyddiad / Date: 25/09/2014 Area discussed in 2012 for Dylan Rattray and Jac Bonner yddiad / Date: landscaping Footpath Bridleway Possible line taken by Land owned by SNPA Dylan Rattray and Jac Bonner Graddfa / Scale: 1:3000
354000 355000 Map D: Initial route plan 261000 262000 263000 sd ir Wyddfa/- on Snowdon. ,,, + Tal Level ee a Tlalev Glaslyn cP aye fen = Ste Sa sue Ney! Po aN Miners Track? ° # ~, a "'Sheepfoid ty (is) Sheepfol (dis) he a toys Carreg Gwalch>. ig an lis © Za Clogwyh Pen > oo Uechen *~ or Grey Cliffs AS : = ¢ a sheepfo| (dis) Cwm Tregalan ooosse O00rsE 261000 ==nes== Footpath === Bridleway oe Crib Goch desire line East Ridge desire line Likely route by 6 @ Dylan Rattray and Jac Bonner Possible line taken by Dylan Rattray and Jac Bonner Initial route plan for descent Dyddiad / Date: 25/09/2014 Land owned by SNPA Graddfa / Scale 1:10000 Lluniwyd Gan / Compiled By: LJ (GIS Officer) © Hawlfraint y Goron a hawliau cronfa data / © Crown copyright and database rights, 2014, Ordnance Survey 100022403 Hawlfraint Awdurdod Pare Cenedlaethol Eryri / Copyright Snowdonia National Park Authority Awdurdod Parc Cenedlaethol Eryri Snowdonia National Park Authority Swyddfa'r Parc Cenedlaethol ~ National Park Office Penrhyndeudraeth Gwynedd G@ 01766 770274 LL48 6LF
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.
SNOWDONIA NATIONAL PARK Cyswile - Contact Fien - Telephone Ein cyt Quy ref ewes Mogwiak \J/JO PARC CENEDLAETHOL FRYR] Hei enaid gael lonvdd Dyddind. Date 6" Octo ( aid gael [lony e-biist = apts SNOWDONIA NATIONAL PARK one of Britein’s breathing Spices Ms Nicola Jones Deputy Coroner for North West Wales Pritchard Jones & Lane 37 Y Maes Caernarfon Gwynedd, LL55 2NN Dear Madam, Your Regulation 28 Report to prevent future deaths arising from the inquest into the unfortunate and tragic death of Dylan Arwel Rattray has been Passed to me as the The Report highlights three main areas of concern and | Shall respond to each area individually in due course. Prior to doing so however | consider it will be useful for you to understand Snowdonia National Park Authority's Statutory purposes and any duties arising therefrom. Snowdonia National Park Authority was established by the Environment Act 1995 asa single purpose local authorit . Ithas the following Purposes as defined by the Act: e To conserve and enhance the natural beauty, wildlife and cultural heritage; and ° To promote Opportunities for the understanding and enjoyment of the special qualities of the (National) Park by the public. The Act goes on to Say that in pursuing National Park Purposes the National Park Authority shall seek to foster the economic and social wellbeing of local communities within the National Park and shall for that purpose Co-operate with local authorities and public bodies whose functions include the Promotion of economic and social development within the area of the National Park. Additionally under the Environment Act 1995 the Authority is the local planning authority for the whole of the National Park. The Authority is therefore responsible for the production of the Park Management Plan, Local Development Plan and for the determination of planning applications. Whilst there are other statutory duties applicable to the Authority, the main one of relevance to this matter is the legislation appertaining to the Countryside and Rights of Way Act 2000 (hereinafter referred to as CROW). This Authority has responsibility under CROW as the “relevant authority” for areas define saben access land”. | can confirm that the entire route followed by Mr Rattray and i estion j ccess land. a However, this does not extend to responsibility for personal Safety and responsibilities under CROW include issuing short or long term restrictions and exclusions i.e. for nesting restrictions for the prevention of danger to the public that are man-made e.g. pollution / unexploded munitions / fire etc. here is also the power if the Authority so wishes to Provide stiles and gates for accessing and egressing CROW access land. CROW provides the following rights set out in Section 2(1) of the ACT: “2 Rights of public in relation to access land. (1)Any person is entitled by virtue of this subsection to enter and remain on any access land for the purposes of Open-air recreation, if and so long as— (a) he does so without breaking or damaging any wall, fence, hedge, stile or gate, and (b) he observes the general restrictions in Schedule 2 and any other restrictions imposed in relation to the land under Chapter II.” CROW does however specifically restrict any occupiers’ liability and in order to assist you | copy below the relevant section: “13 (2) In section 1 of the Occupiers’ Liability Act 1984 (duty of occupier to Persons other than his visitors), after subsection (6) there is inserted— “(6A) At any time when the right conferred by section 2(1) of the Countryside and Rights of Way Act 2000 is exercisable in relation to land which is access land for the purposes of Part ! of that Act, an occupier of the land owes (subject to subsection (6C) below) no duty by virtue of this section to any person in respect of— (a) a risk resulting from the existence of any natural feature of the landscape, or an ly river, stream, ditch or pond whether or not a natural feature, or (b) a risk of that Person suffering injury when Passing over, under or through any wall, fence or gate, except by Proper use of the gate or of a stile. (6B) For the purposes of subsection (6A) above, any plant, shrub or tree, of whatever Origin, (a) with the intention of creating that risk, or (b) being reckless as to whether that risk is created.” the management of Snowdon in general there are in fact six main paths to the Snowdon which are on legal rights of way. Although these are in fact the legal responsibility of Gwynedd Council this Authority does in fact Manage and promote these main paths on behalf of Gwynedd Council. However, all walkers on these six main paths are reasonably expected to take responsibility for themselves and we would also encourage them to use adequate footwear, clothing and equipment and to have undertaken some form of pre-route planning before Setting out. With this in mind the Authority puts Significant time and resources into promoting mountain safety messages and specifically targets the “pre- visit” phase by Providing precise route descriptions for all of the main paths referred to above. Turning to summit of The area in question where Mr Rattray fell to his death is not in fact in the ownership of the Authority but rather is owned by the Baron Hill Estate. Neither is the area in question on one of the six main paths that this Authority actively maintains and promotes. Having provided you with some background information that | hope you will find of use | shall now respond in detail to your report. You have raised three matters of concern in your report and | shall now deal with each of these separately: 1. Whilst it is acknowledged that Snowdon is an inherently dangerous terrain which attracts millions of walkers of all abilities every year without incident in most cases, | am concerned that the Snowdonia National Park Authority have chosen not to follow the advice of an organisation such as the Llanberis Mountain Rescue Team which has been given in writing on two occasions detailing how the risk of future deaths and serious injury could be reduced. Response: 1 2 3 4 ~~ ) ~~ ~~ Llanberis Mountain Rescue Team first wrote to the Authority on 18" April 2012 detailing its concerns following the death of a walker in poor weather conditions. The walker in question was both experienced and well equipped. It is perhaps unfortunate that no representative from this Authority was called to give evidence at the inquest to Mr Rattray’s death as further details could have been provided at that time. Following said letter a meeting took place with a representative from the Llanberis Mountain Rescue Team on 22" May 2012. At that meeting the following was agreed: A direction pillar was to be placed between the summit and the back of Hafod Eryri so that walkers know the location of the Watkin Path. | have attached a photograph (marked No. 1) which confirms that this work was subsequently undertaken. Some improvement may be needed to the top of the Watkin Path to provide more definition. However this would necessitate the moving of the definitive right of way. Following on from the above, landscaping the south-east face of the summit to remove where possible path braiding and erosion scars. To further discuss the practicality of building some form of low level wall surrounding the area of the summit under the trig point. At that meeting it was made clear that no remedial work on the East Ridge route would be undertaken as although it is not a managed path and not a definitive Right of Way it is none the less recognised as part of the Snowdon Horseshoe in guidebooks etc. The directional pillars were sited on Snowdon in May 2013. Following discussion with the Mountainsafe Partnership (a partnership set up to foster safety on Snowdon and whose membership consists of the British Mountaineering Council, Mountain Training, North Wales Mountain Rescue Association, Plas y Brenin, North Wales Police, Llanberis Mountain Rescue Team as well as other interested parties), landowners, the Local Access Forum together with additional significant input from the Llanberis Mountain Rescue Team - 6 of these directional Pillars were sited on Snowdon at agreed specific points where evidence suggests that navigational errors were change the lines of two public Rights of Way was initiated by the Authority in Conjunction with Gwynedd Highways some time ago and is currently in its consultation phase. The Llanberis Mountain Rescue Team were kept informed during this time and no further letter was in fact received until 23 April 2014 (dated 20" April 2014) and was written following the unfortunate death of Mr Rattray. This letter was unexpected in its contents as the Authority had implemented an action plan that had been agreed with Llanberis Mountain Rescue Team. This Authority has considerable experience and expertise with regard to visitor safety management Principles in the uplands and in area as well as many other areas in Snowdonia and are continuously creating small paths and tracks. This is part of the reason why it is an accepted upland management principle that paths such as these are not broken up. Between the two incidents referred to in this letter it must be remembered that approximately one million people had ascended and descended the mountain on foot. Although the accidents occurred in a similar area the circumstances were markedly different with weather conditions and visibility poor on the day of the 2012 incident. This accident was deemed to have occurred due to navigational error by inadvertently straying from the East Ridge. The weather conditions at the time of Mr Rattray’s accident were, by contrast, considered to be perfect. | have attached a map with this letter (marked “Map A’) that shows the likely route taken by Mr Rattray and The final stages of their route is shown in greater detail on the further map (marked “Map B”) which is an inset map with aerial photography captured in 2013. The hatched area shows the area of land that was discussed for possible screening in 2012. As can be seen from the likely route and subsequent possible line taken by Mr Rattray and ae is highly unlikely that this had any impact whatsoever in the tragic accident that was to follow. It is likely that Mr Rattray and BS initially followed the East Ridge. As previously stated this is a recognised path but not one that is maintained or promoted by this Authority. Had they continued along the East Ridge Pen y Pass. Alternatively they could have continued along the ridge over Lliwedd and down to Llyn Llydaw, returning to Pen y Pass to complete the Horsehoe. For whatever reason however, it appears that Mr Rattray led in an attempt to cut across to Llyn Glaslyn, and by doing so left the relative safety of the East Ridge route that then led to such tragic consequences. 2. The deceased in this inquest was a sensible, fit, hardworking young man, not a foolhardy risk taker. He followed what he thought was an established path that would take him down to Glaslyn. Had the Park taken the previous advice of the Llanberis Mountain Rescue Team to break up these misleading paths then this death would not have occurred as the deceased would not have attempted to descend the route that he took, which led to his death. Response: The Authority takes issue with this point of concern. | attach a paper by I and SE entities “Mountain Rescue Incidents on Snowdon”, This research shows that males were far more likely than females to be involved in incidents and that both Mr Rattray and Eo ctuaiy fell into the category most likely to be rescued. As a result the Mountainsafe Partnership worked to develop a smartphone app specifically for this age category because they are at a higher risk of being involved in incidents. The Authority's Senior Warden for the North of the Park actually spoke to both Mr Rattray and [Jas they set out on their walk from Pen y Pass. The conversation occurred at approximately 2pm. They were standing looking at a map of Snowdon by the Pay and Display looking at the main footpaths remembers the conversation as he had not heard many walkers conversing in Welsh that day and he enquired where they were headed. They informed him that they were going to do Crib Goch but that they weren’t sure where to leave the PYG track in order to do Crib Goch. EM replied “Bwich y Moch, by a dry stone wall” and remembers saying next “Are you sure you know what's ahead of you?” One replied that he did. then asked whether they were going to the summit and the response from one was “no, it’s too busy, and I’ve been to the summit before aa then asked “What will you do then — return down the PYG from Bwich Glas?” Both replied that this was what they would be doing. Although it was quite late in the day to begin such a walk compared to the many hundreds who had traversed the mountain earlie assessed that there was plenty of daylight hours left for the planned route. | attach a further map (marked “Map D”) which shows the planned route as explained tol HE and the actual route subsequently followed. On the question of equipment noted that one was wearing trainers and that both had small rucksacks. It later transpired that neither had a guide book, map or compass. The possession of such simple equipment would no doubt have informed them that there was in fact no suitable route from the East Ridge to Llyn Glaslyn. Having talked to a number of experienced walkers all have expressed an opinion that it should have been clear, particularly given the extremely favourable weather conditions on the day and the obvious nature of the terrain, that to attempt what they did was in fact what could only be categorised as an extreme risk. This is perhaps borne out by the testimony a at the Inquest. [J who was following Mr Rattray, asked Mr Rattray on no less than three occasions for him to turn back. The third and final request was only made about one minute before Mr Rattray’s fall, Unfortunately Mr Rattray chose not to acquiesce to his friend’s request. such paths peter out and leave walkers in perilous positions, then I am satisfied that there will be repeated deaths in these circumstances on Snowdon. Response: The point should be made at the outset that this is not about budgetary constraints. | attach for your information Visitor Monitoring Figures for Snowdonia National Park for “Where risk arises from natural features, such as cliffs, rivers, streams, lakes, falling trees and rocks, it is not desirable to restrict access or take other measures that diminish the amenity simply from fear that an accident may result in prosecution. People should be allowed to Participate in leisure pursuits such as bungee jumping and water sports that are potentially hazardous.” The case of Tomlinson v Congleton Borough Council — Brereton Heath Country Park is mentioned where Lord Hoffman's opinion was that: “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 that 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 people not to undertake risky activities on his land.” This however is not an option on Snowdon as it is Open access land as defined by CROW but this is perhaps reflected in the fact that CROW has intentionally limited liability for natural features. The above does not of course mean that the Authority does not take visitor safety seriously but the reality is that all mountains have false paths and walkers should be aware. Referring once more to the report entitled “Mountain Rescue Incidents on Snowdon’ it can be seen that overall the accident rate averaged over the period was 69 hours for every million hours spent on the mountain but that if uninjured callouts are excluded then this falls to 30 for every million hours on the mountain. This is in fact a lower rate than for mountaineering in general (40), horse riding (100) and football (1300). In fact it is comparative to the sport of fishing (30). Such an accident rate is perhaps a testimony to the hard work put in by the staff of this Authority in maintaining the six main routes, by the Park Wardens in advising members of the public and by the significant amount of information that the Authority provides freely via its website. This does not of course mean that the Authority is complacent as to the future. The challenges of Snowdon are in many ways unique from the sheer number of visitors, to the challenging conditions that the Authority's workforce face in maintaining the maintained routes in suitable condition. The provision of signage and re-routing the Watkin Path will hopefully ensure walkers are provided with more information and a clearer route. What is almost certain however is that these measures would not have affected the outcome of this unfortunate accident. | trust that the above adequately explains the Authority's position in this unfortunate incident. If you require any further clarification please do not hesitate to contact me. Alternatively, if you wish to see the area for yourself | can confirm that one of our Wardens for Snowdon would be more than happy to accompany you on any fact finding visit. reuts faithfully, Director of Corporate Services. Encs.
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