Prevention of Future Deaths reports · 2015

Scarlett Jukes

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 report27 Oct 2015
Reference2015-0449
DeceasedScarlett Jukes
CoronerPeter Harrowing
Coroner areaAvon
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)

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

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)
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

Related reports

Other reports by Peter Harrowing

See all →

More reports categorised “Other related deaths”

See all →

Track Peter Harrowing

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.