Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0285, written 20 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2015 |
|---|---|
| Reference | 2015-0285 |
| Deceased | Bradley Hooper |
| Coroner | Grahame Short |
| Coroner area | Hampshire (Central) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. MC Federation 2. Portsmouth Motocross Club 1 | CORONER | am Grahame Antony Short, senior coroner for the coroner area of Central Hampshire 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 14 May 2014 | commenced an investigation into the death of BRADLEY MARK HARRY HOOPER aged 16 years. The investigation concluded at the end of the inquest on 14 July 2015. The conclusion of the inquest was that he died due to multiple injuries caused by a motor collision and | recorded a conclusion of Accidental Death. 4 | CIRCUMSTANCES OF THE DEATH At about 10.28 on 11 May 2014 Bradley Hooper was riding a Honda motorbike in a club practice session at the motocross circuit at Down Farm Headbourne Worthy near Winchester. After mounting a flat topped jump near marshalling point 11, he came off his machine as the bike landed and was in the process of picking it up when he was struck from above by a Yamaha motorbike being ridden by another rider who had just gone over the same jump, but had no warning of his presence. 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. — 1. The evidence showed that the marshall at Point 11 had earlier been using his mobile phone to take photographs of passing riders and at the time of the incident was facing in the opposite direction to the direction of travel of the riders, so that he was unaware of Bradley Hooper coming off his machine and did not show a yellow flag until after the fatal collision. The MCF Code of Practice makes no reference to appropriate warnings which should be given to marshalls at briefings about the use of smartphones whilst practices or races are under way. 2. The marshall at Point 11 was aged 16 at the time of the incident and had only marshalled on one previous occasion. Although he claimed to have made this known to the Chief Marshall no action was taken to allocate him to a low risk position, notwithstanding the current club marshalling rules of Portsmouth Motocross Club which states that those aged 16-18 should be so allocated. | consider that Portsmouth Motocross Club should ensure that marshalls are allocated to positions based on the experience of each individual and that it should review its rules in light of the MCF Code of Practice (once that is updated) and its affiliation to MCF. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 15 SEPTEMBER 2015. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 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. 20 July 2015 CO Ath
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.
Portsmouth Motocross Club | Event Secretary 34 Trevose Way * Titchfield Common * Fareham + PO14 4N Tel: (01489) 571493 + — G AShort Senior Coroner Coroner’s Office Castle Hill The Castle Winchester $023 8UL 7 September 2015 The late Bradley Mark Harry HOOPER Dear Sir Further to the investigation and inquest following the death of Bradley Hooper at Down Farm, Headbourne Worthy, Winchester on Sunday 11™ May 2014 and the subsequent actions required to take place following the conclusion of Accidental Death. Please be aware that the following actions have been in place from the initial meeting hosted by Portsmouth Motcross Club, following Bradley's death, and have been and will be in place for the remainder of the season and all further race meetings. These actions will continue to remain in place in order to add further preventative procedures to avoid any further risks of death. Ihave attached the updated Rules of Marshalling, which is read out at every race meeting, in the Marshals Brief, and also handed out to each individual Marshal allocated to a Marshal Point on the day of the event. @ All Marshals are briefed before going to their allocated Marshal Point, and ALL Marshals are asked if they understand the Rules of Marshalling before they are permitted onto a Marshal Point. ¢ If any Marshal is unsure of any Marshalling ruling, they will not be permitted to sign the declaration form, and therefore will not be permitted onto a Marshal Point. @ Experienced Marshals (with 6 or more sessions of Marshalling history) are placed on “high-risk” Marshal Points. ¢ “High Risk” Marshal Points will be determined by the MC Federation, and highlighted on the course map which will be followed by the Club. continued /.... @ less experienced Marshals (with no or limited Marshalling history) are placed on “low-risk” Marshal Points. @ ALL Marshals are instructed what each marshalling flag is to be used for: ¢ Static Yellow Flag — fallen rider * Yellow Flag Waved Vigorously — fallen rider in danger, suspected injury ¢ White Flag with Red or Green Cross — rider requiring urgent medical attention @ ALL Marshals are informed that they are not to use mobile telephones on the Marshal Point when motorbikes are on the course circuit. @ ALL Marshals are informed that they are to look the opposite way of the oncoming motorbikes (ie. with the bikes travelling from behind their Marshal Point). ®@ Additional “floating” Marshals will be positioned at various locations on the circuit to ensure those Marshals placed on Marshal points, are acting in the correct manner. Portsmouth Motocross Club believes these new measures can prevent any further serious injury or death in the future. Yours faithfully Event Secretary Portsmouth Motocross Club Enclosed: Appendix A - Portsmouth MX Club — Rules of Marshalling cc DAC Beachcroft Claims Limited MC Federation Limited | Chairman, Portsmouth MX Club -2- APPENDIX A PORTSMOUTH MX CLUB RULES OF MARSHALLING YOU MUST ENSURE THE SAFETY OF THE TRACK BETWEEN YOUR MARSHAL POINT AND THE NEXT Marshals should be 16 years of age or over (If aged over 65 years, you must be physically able to carry out marshal duties) You must always LOOK IN THE DIRECTION THAT THE RIDERS ARE TRAVELLING (with the bikes coming behind you) Make sure you can see the next marshal point You must NOT USE A MOBILE PHONE whilst any racing or practicing is taking place You must keep the yellow flag in your hand AT ALL TIMES You must NEVER LEAVE your marshal point to assist a fallen rider You must NEVER LEAVE your marshal point unattended during racing You must RAISE THE YELLOW FLAG if a rider falls in your area You must WAVE THE YELLOW FLAG energetically if the incident is of a serious nature You must RAISE THE RED/WHITE or GREEN/WHITE FLAG if a rider appears to need medical attention Only the person signed on as a marshal is allowed on the point You are duty bound to stop unauthorised persons from entering prohibited areas If you wish to leave your marshal point you must inform an Official Do not allow a person who has not signed on to take over your marshal point NO CHILDREN or DOGS are allowed on the marshal point The YELLOW FLAG warns others riders to proceed with caution and maintain their position — there is to be NO OVERTAKING when a yellow flag is raised. If any rider ignores your flag, you must report them to an Official for the safety of the others riders, Officials or Medics
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