Prevention of Future Deaths reports · 2015

Carl Hughes

Regulation 28 report to prevent future deaths, reference 2015-0429, written 6 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Nov 2015
Reference2015-0429
DeceasedCarl Hughes
CoronerMichael Singleton
Coroner areaBlackburn, Hyndburn & Ribble Valley
CategoryOther 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)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS |

THIS REPORT IS BEING SENT TO:
The Chairman

Motor Cross Federation

The Stables

Little Baldon Farm

Little Baldon

Oxfordshire

0X44 9PU

1 CORONER

I am Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn &
| Ribble Valley.

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.

ns

3 INVESTIGATION and INQUEST

On the 10" August 2015 I commenced an investigation into the death of Carl Hughes aged
32 years. The investigation concluded at the end of the Inquest which was concluded on
the 4°" November 2015. The conclusion of the Inquest was that Carl Hughes had died of an

accidental death during a Motor Cross event held at Catterall’s Farm.

4 CIRCUMSTANCES OF THE DEATH

On Sunday 2" August 2015 Carl Hughes was taking part in a motocross event run by the
Newton-le-Willows Motor Cross Club which is affiliated to the Motor Cross Federation.
During a novice event he fell from his motorcycle and was then run over by another
competitor as a consequence of which he sustained fractures to his back which ultimately
| proved to be fatal.

CORONER’S CONCERNS

5

During the course of the Inquest the evidence revealed matters giving arise to concern. In
my opinion there is a risk that further deaths will occur unless action is taken. In the
circumstances it is my duty to report to you the MATTER OF CONCERN is as follows: -

That during the course of the Inquest I heard evidence that Motor Cross events of this
nature require competitors to wear mandatory protective equipment of helmet, gloves and
boots. It was not however mandatory for competitors to wear body protection. I believe
that had Carl Hughes been wearing body protection it would have been unlikely that he

would have sustained injuries which would have proved to be fatal.

6 ACTION SHOULD BE TAKEN |
|
In my opinion action should be taken to prevent future deaths and I believe you have the
| power as an authorising body to take such action by making body protectors mandatory.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
| namely by 1% January 2016. 1, the Coroner, may extend this 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 person, |
namely:

The Chief Coroner
| Iam 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 06 November 2015 Signed by: a aA Z fort PA th sues

H M Senior Coroner for Blackburn,
Hyndburn & Ribble Valley

tv

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 Respondent Not Named (PDF)
B [L M King’s House, 42 King Street West, Manchester M3 2NU
T +44 (O)161 236 2002 F +44 (0)161 832 7956 DX 14302 MANCHESTER | blmlaw.com

Contact: David Spencer
Direct Line: +44 (0)161 838 6800
Email: david.spencer@blmlaw.com

. Our Ref: DDS/RGB/150283.1/xC
Mr M Singleton Your Ref: MJHS/JKE/C43279/2015

HM Senior Coroner

Coroner's Office

Blackburn Central Library

Blackburn 11 April 2016
BB2 1AG

Dear Mr Singleton

Re: Carl Hughes (Deceased)

Thank you for your letter of 5 April. Please accept my apologies for the delayed response. I appreciate the
time granted under the extension has passed, but our enquiries have not been straightforward.

IT am instructed in the following terms:

The MC Federation

The MC Federation ("MCF") was formed in 2008 with the aim of providing locals clubs and organisations with
support in the planning, organisation and promotion of off-road motorcycle events and competition.

Motorsports, and perhaps particularly motorcycling, has a recognised inherent risk and so participant and
spectator safety are at the forefront of the MCF approach and philosophy.

The MCF are recognised as an authorising body for motorsports events and since their inception, have been
responsible for support and oversight in some 1,500 events across the UK and Ireland. For the 2016 season, it
is anticipated that 300 events will be run with the support of the MCF.

The event in question

Mr Hughes was a participant in a novice event at Catterall’s Farm, Clitheroe. Shortly after the start of his race
(before the second corner) it is reported that he hit a rut and fell from his bike. As he was getting up from the
ground, he was struck from behind by another rider and was knocked to the ground.

He was provided medical treatment from the onsite paramedic. The air ambulance was called, and Mr Hughes
was collected and transferred to The Royal Preston Hospital, where he was admitted.

BLM is a trading name of Berrymans Lace Mawer LLP a limited liability partnership registered in England under number OC340981, authorised and regulated by the Solicitors Regulation
Authority and the Law Society of Scotland. The registered office is at King’s House, 42 King Street West, Manchester M3 2NU where a list of members is available for inspection. BLM Iretand is
affiliated to Berrymans Lace Mawer LLP and the partners are either members or employees of Berrymans Lace Mawer LLP Partners of Berrymans Lace Mawer LLP are members or employees
of Berrymans Lace Mawer LLP and the use of the term “partner” should not be construed as indicating that the individuals so designated have entered into partnership (within the meaning.
of the Partnership Act 1890) with all or any of the individuals so designated or with any individuals and Berrymans Lace Mawer LLP. Berrymans Lace Mawer LLP is certified to infarmation
Security Standard ISO 27001 (BS! certificate SS89484), Quality Assurance Standard (SO 9001 (SGS certificate GB 13/90471) and Lexcel, the Law Society's Practice Management Standard,

The site paramedic reported that given his mobility immediately post-accident, it was not immediately obvious
that Mr Hughes had suffered a spinal injury. The incident was recorded in the usual fashion. A copy of the
steward's report is attached for your consideration.

The MCF do not know the extent of protective clothing / equipment worn by Mr Hughes on the day of the
event, over and above the mandatory items of helmet, gloves, boots etc. That level of detail is not something
that would be recorded.

The aftermath

Again, with information gleaned from press reports, Mr Hughes is reported to have he suffered fractures to 4
thoracic vertebrae. Whilst being treated as an inpatient, and four days after the index event, Mr Hughes is
reported to have died as a consequence of a pulmonary embolism. He is also reported to have had a history
of DVT.

The MCF were not approached by the local authority who investigated the incident.

The MCF were not made aware of the investigation and / or inquest that took place in your Court last year.

The investigation and inquest

Your report concludes with a finding of accidental death “during an event at Catterall’s Farm" and in
circumstances where he sustained “fractures to his back which ultimately proved to be fatal."

Whilst without any of the investigation or medical evidence, given the contradictory reports in the general
press, the MCF would challenge those findings.

Mr Hughes did not die during the event.

The MCF would also challenge that the cause of death was the orthopaedic that Mr Hughes appears to have
suffered. If the general press reports are accurate, Mr Hughes suffered a pulmonary embolism, and had a
history of DVT, itself a primary cause of pulmonary emboli.

It is important to recognise that Mr Hughes was under the care of an expert medical team when he died.
Coroners Concerns

You have identified that following evidence, it was not mandatory for participants to wear body protection,
and that had Mr Hughes been wearing body protection you consider it unlikely he would have sustained

injuries that proved to be fatal. You have identified that action should be taken by the MCF to make the
wearing of body protectors mandatory.

MCF Response

All MCF events are organised under the MCF Regulations, the latest edition of which was issued in August
2015, and a copy of which is attached. On the issue of clothing, the MCF regulations identify, in relation to
protective clothing, that:

1, All competitors must wear a crash helmet...

6. It is advised that all riders and passengers should wear a body belt/kidney protector and
wear protective armour giving protection to at least the chest and shoulders.

9. Inall races and official practice complete protective clothing produced for motocross racing,
knee length boots and gloves shall be worn by each rider and passenger. It is advised that
motocross jerseys should provide protection against abrasion to the body and arms and that
motocross jeans are padded at the hips and knees

Enquiries have been made beyond the MCF with other relevant organisations.

The Auto-Cycle Union ("ACU") is the governing body for motorcycle sport throughout Britain, is recognised by
(and was a founding member of) the Federation Internationale de Motorcyclisme ("FIM") and, amongst other
aspects, sets the rules and sets, checks and revises safety standards for the sport. Under the ACU Motocross
Standing Regulations:

“it is advised that all riders and passengers should wear a body belt / kidney protector and wear
protective armour giving protection to at least the chest and shoulders”

The Motor Racing Association Ireland ("MRA") is the governing body of motorcycle racing in the province of
Ulster. Their regulations state that

“At all competitions.....in which speed is a determining factor, and at other competitions where it may be
required by the authority granting the permit, Competitors must have approved and suitable protective
clothing as generally required for use in the specific sporting discipline.”

The British Schoolboy Motorcycle Association ("BSMA") is a confederation of clubs, set up in November 1969,
who run local and national events. Their regulations require that:

10.8 Adequate protective clothing, jerseys with longs sleeves correctly worn ie; rolled down. Branded
Motocross jeans must be worn. All hoods to be tucked in

10.9 A suitable chest guard and body belt must be worn. When a nylon race shirt is worn the wearing
of a cotton undershirt is recommended.

The Amateur Motor Cycle Association ("AMCA’) is a leading off-road organisation, with over 200 affiliated
clubs, permitting over 900 events annually. At the relevant part, their current (2016) rule book requires, in
addition to conforming helmets and purpose made boots:

“47; e) BODY BELT / KIDNEY PROTECTORS — Recommended to be worn and protective
armour to cover at least the chest and shoulders”

Body Protection

There is no clear or absolute definition of what might properly be regarded as “body protection” and that labet
encompasses a very broad range of equipment in the motocross arena. A straightforward internet search will
show, for example; neck braces, face guards, shoulder, back and chest protection (with soft and hard options,
and as single items, or as a composite piece), elbow braces, guards and pads, wrist braces, kidney belts,
protection shorts, knee cups, knee braces, knee and shin guards and so on. The list of body protection
equipment whilst not endless is very long, and with brand development and competition grows regularly.

Some, but not all competitors wear body belts, and / or protective armour to the chest and / or shoulders.

There will be a variety of reasons for participants not wearing any additional protective equipment; they do

not consider it necessary or worthwhile, that it is uncomfortable, that it restricts movement and so, perhaps

counterintuitively, creates a danger. It may also be that that they simply cannot afford the expense as some
items can be very expensive.

We know also that, despite body protection being worn, riders still fall from their machines or collide with
other participants and suffer injury. The protectors are not absolute protection against, for example, twisting
or rotational injuries, fracture and / or dislocations.

The action to be taken

It must be recognised that motocross has an inherent risk. The MCF remain committed to developing and
promoting a safe sporting environment for motocross. Very serious injury in motocross is not a frequent
occurrence,

Riders falling from their machines, or colliding with other riders is a likely occurrence at every event. Such
incidents do not always lead to an injury being sustained.

It will be recognised that the ACU and other National, established motocross organisations do not mandate
the wearing of ‘body protection’ generally, or even specific items under that general heading.

The MCF do not consider it would be practicable to amend their standing regulations to mandate the wearing
of ‘body protection’; the term is so wide ranging so as to be unworkable.

It would be possible to amend the MCF regulations to mandate the wearing of specific items of body
protection but again, it would not be practicable to do so. There are currently no requirements for the very
wide range of body protection equipment to be CE or BSI approved and so, for example, to require
participants to wear only CE approved equipment would be very limited and may exclude protective
equipment currently being used voluntarily by MCF participants.

Dealing with the case in point, because the precise mechanism of the accident, the protection being worn by
Mr Hughes and the extent of the accidental injury is not known, it is possible that the same injuries could have
been sustained had body protection been worn.

If the MCF did mandate the wearing of ‘body protection’, whether generally or specifically, there is the very
real risk that those current members and participants will choose not to take part in MCF events. It is
anticipated that the requirement to purchase the equipment may be an expense too far for some, or
alternatively that it will be seen as unnecessary and some extension of a “Nanny State."

That process has two potential outcomes. Either the participants will stop taking part in motocross altogether
or they will move to events run by other organisations (or events that have no formal organisation) where the
wearing of ‘body protection’ is not mandatory.

Creating a situation where people simply do not take part cannot be an intended consequence of the
proposed action. Further, in absence of an industry-wide requirement, then singling out the MCF to make the

wearing of body protection mandatory simply displaces the issue.

Whilst the MCF remain committed to safety, they will not be taking action to mandate the wearing of body
protection at their events.

I trust this adequately explains my client's position.

If further information is required, then please do not hesitate to contact me.

Yours sincerely

David Spence’
Partner
BLM

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