Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0449, written 27 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Oct 2015 |
|---|---|
| Reference | 2015-0449 |
| Deceased | Scarlett Jukes |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Master of Foxhounds Association 2. Partner of the Deceased 3. Health and Safety Executive 4, Chief Coroner CORONER | am Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon 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 On 26th February 2015 | commenced an investigation into the death of Ms. Scarlett Jukes age 54 years. The investigation concluded at the end of the inquest on 9th September 2015. The conclusion of the inquest was that the medical cause of death was I(a) Traumatic head injury, and the short-form conclusion as to the death was that of accidental death. 4 | CIRCUMSTANCES OF THE DEATH On 28th January 2015 Ms. Jukes was participating in a Trail Hunting event with the pack of foxhounds. Whilst riding along a country lane Ms. Jukes’ horse lost its footing following recent hail and she was thrown head first from the horse. During her fall her riding hat came off. Her head struck the tarmac and she suffered a severe traumatic head injury. She was administered first aid at the scene and was attended by the paramedics. Ms. Jukes was taken to hospital where she underwent surgery. However, despite all best efforts of the neurosurgeons she died on 14th February 2015. The riding hat worn by Ms. Jukes was a traditional hunt cap which did not have a chin strap and did not comply with current national and international safety standards for such protective headgear. The manufacturer's of the hunt cap state clearly on the cap that it is not intended to provide protection against personal injury and did not comply with relevant safety standards. 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) Members of the public who participate in such hunting events (i.e.'subscribers’) are not required to wear protective head gear which complies with any relevant safety standards. (2) Hunt staff who are paid employees of each hunt and whose work can involve significant time riding horses are not required to wear head gear designed and manufactured to recognised safety standards. (3) The current recommendations of the Master of Foxhounds Association (MFHA), the governing body, published in October 2008 provides that hunt staff should be permitted to choose whether to wear a traditional hunt cap which does not comply with recognised safety standards or to wear a ‘modern hat’ which does comply with the required safety standards. (4) The MHFA should act to ensure that all hunt staff are required to wear protective headgear designed and manufactured to recognised national and international safety standards when riding horses during the course of their employment. (5) The MHFA should act to ensure that all members of the public, whether subscribers or otherwise, when participating in events under the auspices of the MFHA are required to wear protective headgear designed and manufactured to recognised national and international safety standards. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 22nd December 2015. |, 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 partner of the deceased, and the Health and Safety Executive | shall send a copy of your response to EEE and the Health and Safety Executive. | have sent a copy of my report to the Chief Coroner. | 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. 27th October 2015 Assistant Coroner Sn heneneny
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.
MFH ASSOCIATION Overley Barn, Daglingworth, Cirencester, Gloucestershire. GL? 7HX Tel: 01285 653001 Email: office@mfha.co.uk Mobile: 07867 975701 Website: www.mifha.co.uk Fax: 01285 653559 22 DEC 208 18'" December, 2015 Dr. Peter Harrowing, HM Assistant Coroner, The Coroner’s Court, The Courthouse, Old Weston Road, FLAX BOURTON. BS48 LUL Dear Dr. Harrowing, Inquest into the death of Ms. Scarlett Jukes Regulation 28 Report to prevent future deaths I wrote to you on 12" November, to confirm that the MFHA would respond within 56 days to yout letter of 27" October, 2015. MFHA Powers You have determined that the MFHA is the organisation with the power to take action to prevent future deaths. This is only partially correct, in that the MFHA has a regulatory role only in respect of those Hunts that are members of this Association, but not over Hunts that operate under of the Association of Masters of Harriers and Beagles, the Masters of Deerhounds Association, and the Masters of Draghounds and Bloodhounds Association, which currently collectively number approximately 105 Hunts. There are also a number of un-registered Hunts, with which the MFHA has no contact. The MFHA does have authority over its own members, and listed below are the relevant powers extracted from the MFHA Constitution, Rules and Recommendations 2008: A.4. (3). Power to regulate Recognised Hunts. A.4. (5). Power to recommend new or revised Rules for approval by the AGM. A.4. (7). Power to issue Instructions, which will only be valid for 12 months, when they either have to be renewed or incorporated in the Rules. A.4. (8). Power to issue Guidance Notes. Director: Tim Easby -2- In your letter at Paragraph 5 you refer to the Guidance Notes published by the MFHA in 2008. While the MFHA both sets rules and issues guidance notes, these apply only to the Hunts registered with the MFHA, and do not apply to the members of the other Hunting Associations. The MFHA regulates the activity of hunting, including the management of a Hunt country, and the welfare and breeding of hounds. It has never sought to regulate those who participate in hunting, including staff employed by individual Hunts. The MFHA is not a regulatory body like, for example, the Football Association or the British Board of Boxing Control, both of which regulate commercial operations with significant budgets and large numbers of professional staff, neither of which the MFHA has. Furthermore, the MFHA has virtually no sanctions apart from expulsion, which is rarely used, and obviously only then in extreme circumstances. The sanction of expulsion would have the consequence of the Hunt concerned operating independently. It would not prevent the Hunt from operating. Hunting is fundamentally a voluntary community activity, with no commercial operators or activities. While most Hunts may employ one or two, and sometimes more, professional staff — not all of whom are mounted, the activity of hunting is entirely dependent upon a large number of supporters, at a local level, doing an enormous amount of voluntary work to enable their local Hunt to operate on two, three or four days each week throughout the season. The Rules set out above show that the MFHA has wide powers to adopt, instigate and enact new rules. Proposed new-rules are discussed by the Committee at its regular meetings and, if agreed, are then put to the next Annual General Meeting for the members to approve or otherwise. However, the Committee is unlikely to recommend rules that it believes would not be widely accepted and adhered to by members and the wider hunting community, and in these circumstances the voluntary nature of hunting lends itself better to the issuance of Guidance Notes. The Association cannot compel members to follow any guidance issued. Background The Committee of the MFHA takes the safety and well-being of everyone involved in hunting extremely seriously, and has re-visited the issues around head-wear regularly. It is, however, not as straight forward as it may appear. Over the years hats have evolved and as part of that process the safety of particular hats has been reviewed. In 2008 the MFHA commissioned, with legal and other expert advice, a detailed report on the protection provided by different types of hats. A lot of effort went into ensuring that the 2008 report came to a sensible conclusion, based. upon the evidence. Detailed information was provided by Hunts about all relevant accidents (very few were recorded) and these were carefully reviewed. In addition, a leading hat manufacturer assisted in subjecting the traditional hunt cap to extensive crash testing. The outcome was that, while the traditional hunt cap was found to provide inadequate protection from a side impact, it did provide a satisfactory level of protection for a head-on impact. Head-on impacts (i.e. falling off a horse directly on to hard ground) is the primary factor in -3- accidents (rather than side impacts), and it was concluded that the traditional hunt cap provided sufficient protection against the types of accident that Hunt Staff were likely to have. Other important factors were also taken into account, including safety in hunt-specific situations, such as riding through undergrowth and woodland, where the wearing of a modern safety hat with a chin strap could result in serious neck injuries where the hat hit a branch and did not come off (because of the chin strap). The great majority of (employed) respondents also confirmed that they had a strong preference for wearing a traditional hunt cap in the hunting field. Despite encouragement to adopt modern safety hats with chin straps, this remains the case today. Hunt Staff The MFHA recognises that Hunts owe a duty of care towards their professional employees and other staff, to ensure that they are safe in the workplace and are provided with satisfactory equipment and appropriate protective equipment: relevant legislation and statutory instruments include the Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations, the Provision and Use of Work Equipment Regulations and the Personal Protective Equipment at Work Regulations. The MFHA, through Guidance Notes and regular training seminars, make clear to Hunts that a breach of health and safety regulations is a serious matter and can result in criminal prosecutions. The burden very much therefore falls on the individual Hunt, as the employer, to make sure that the equipment is safe. The MFHA’s guidance to Hunts states that, where a staff member wears a traditional hunt cap, it: 1. Should be professionally checked by the manufacturer at least every three seasons and ideally every two seasons. 2. Should be professionally checked by the manufacturer whenever the rider suffers a fall or the hat suffers any other damage. 3. Should be allowed to dry for 36 hours before being worn again, and consequently any member of staff hunting four days a week should be provided with a second hat. 4, Should be correctly fitted and, if the rider has any concerns about this, an appointment should at once be made with the manufacturer for the hat to be checked and refitted if necessary. It was on this basis, that the MFHA decided in 2008 that it could safely continue to advise members that Hunt staff be given an unfettered choice as to whether they wish to wear a traditional hunt cap or a modern safety hat. Hunt Subscribers Participants in hunting do so in a variety of different ways; on horseback and on foot, by bicycle and by car. The MFHA maintains no records of Hunt followers, has no rules about the way followers should conduct themselves, and it has never before been suggested that it should provide advice or guidance to followers in relation to the manner in which they participate. The Association would not be in a position to do so, which is why traditionally, this has been a matter for individual Hunts. Currently, the MFHA has no facility to communicate with followers directly and, while the Hunts clearly have a duty of care towards their employees, we are advised that they currently have no legal duty of care towards followers. Nonetheless, in light of your letter and Scarlett Jukes’s tragic accident, we have concluded that we should now carefully consider the safety of Hunt followers (as well as Hunt officials such as Masters who are not employed), given the recent accidents. Proposed review of hats and safety The MFHA has already initiated a full review of the hats currently used for hunting, both for professional Hunt staff and Hunt followers, and to help inform the review has already instigated a further detailed evidence gathering exercise amongst Hunts and Hunt staff. The review will involve further expert crash testing of all currently available traditional hats, and a wide consultation. It is hoped that the review, and any further work emanating from it, will be available for the MFHA Committee prior to its next meeting. It is clear thai it will also be necessary to issue new Guidance Notes, not least because guidance has hitherto not been issued for Officials and Subscribers. The aim is produce this Guidance Note in time for approval at the MFHA AGM in June, 2016. I want to assure you that the MFHA will further take whatever steps its review of hats and safety indicates may be desirable to limit the risks to professional Hunt Staff and followers, bearing in mind that following hounds across country can never be entirely free of risk. Yours sincerely, Tim Easby Director
See every Prevention of Future Deaths report matching Peter Harrowing, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.