Prevention of Future Deaths reports · 2014

Dylan Rattray

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 report12 Aug 2014
Reference2014-0371
DeceasedDylan Rattray
CoronerNicola Jones
Coroner areaNorth West Wales
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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
Also filed under 2014-0371: MapAa3_1869316399.pdf
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Also filed under 2014-0371: MapBa4_1869316399.pdf
Map B: Inset Map with aerial photography captured in 2013

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Also filed under 2014-0371: MapDa3_1869316399.pdf
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Land owned by SNPA

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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

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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 Snowdonia Park1 (PDF)
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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