Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0170, written 25 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 May 2017 |
|---|---|
| Reference | 2017-0170 |
| Deceased | Bonamie Armitage |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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H M Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (addresses provided separately) (1) The Cotswold Hunt (2) The Council of Hunting Associations and the Director of the Masters of Foxhounds Association CORONER | am Katy Skerrett, Senior Coroner for Gloucestershire. 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. INVESTIGATION and INQUEST On the 4/4/2016 | commenced an investigation into the death of Bonamie Elena Miriam Armitage. The investigation concluded at the end of the inquest held before a jury on the ch May 2107. The conclusion of the jury was a short form conclusion of accidental death. The medical cause of death was 1A haemopericardium, 1B impact trauma to the anterior central chest. CIRCUMSTANCES OF THE DEATH Bonamie Elena Miriam Armitage * ‘Bonnie” was a 9 year old girl who was an experienced and competent rider. On the 2™ April 2016 the Cotswold Hunt met for the last trail hunt of their season. Bonnie was taking part in the Hunt on her Shetland pony. Bonnie was under the supervision of a family friend, who was looking after five children (including Bonnie) on that day. Bonnie was wearing a body and shoulder protector, and a riding hat. Approximately 50 riders met at Miserden house. Riders set off at around 11am on the pre determined course. During the course of the hunt, the family friend and the younger children were towards/ at the back of the hunt. Bonnie was at the back. ye horse ridden by another rider came int Bonnie’s pony and a larg lose proximity with each other. As the two horses came close together, the larger horse kicked out. Bonnie was struck in the chest, and died as a result of injuries sustained from the kick to her chest. Paramedics attended, and despite extensive resuscitation efforts Bonnie died as a result of the injuries she had received. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. noted that none of these factors was causative in this particular case, in my aie there i 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) There is no mandatory requirement that all child participants in a Hunt are required to wear personal protective equipment, (2) There is no mandatory requirement that all child participants in a Hunt are required to demonstrate an established level of competence before participating in a Hunt, (3) There is no mandatory requirement that children are supervised by adult riders when participating in a Hunt, and no ratio of adult supervisors to child riders is stipulated. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 4pm 24" July 2017. |, 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 Thi opy of my report to the Chief Coroner and to the following Interested Persons (1) counsel for the family, 1 Harcourt Buildings, Temple, London EC4Y 9DA (2) Commercial Services manager/Safety Adviser, Stroud District Council. Ebley Mill, Westward Road, Ebley, Stroud, GL5 4UB (3) [IE — soiicitor for a rider at Hunt, DAC Beachcroft Claims Ltd, Portwall Place, Portwail Lane, Bristol BS1 6NA | 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. Dated 25" May 2017 Signature Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305662 | Fax 01452 412618
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 Email: office@mfha.co.uk Website: www.mfha.co.uk 24th July, 2017 Ms. K. Skerrett, Senior Coroner for Gloucestershire, Gloucestershire Coroner’s Court, Corinium Avenue, Barnwood, GLOUCESTER. GL4 3DJ Dear Ms. Skerrett, Inquest into the death of Bonamie Elena Miriam Armitage Regulation 28 Report to Prevent Future Deaths As the Director of the Master of Foxhounds Association (MFHA), I am writing in response to the Report sent to my organisation dated 25th May, 2017. You have determined in paragraph 6 of that Report that in your opinion action should be taken to prevent future deaths and that my organisation has the power to take such action. You should be aware that the powers of the MFHA are limited. Whilst we as an organisation regulate hunting there are many Hunts that are outside any jurisdiction that we might have. By way of example, the MFHA does not regulate Hunts that operate through the Association of Masters of Harriers and Beagles, under the Masters of Deerhounds Association and the Masters of Draghounds and Bloodhounds Association. In addition, there are a number of unregistered 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.A(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. 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. Director: Tim Easby -2- 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. MFHA Guidance The MFHA has issued guidance in the past relating to health and safety of Hunt staff, but has never sought to regulate hunting by way of guidance to those who subscribe to Hunts or who ride with Hunts as guests. The MFHA maintains no records of Hunt followers and has no rules about the way in which they conduct themselves. We have in the past issued guidance on such matters as headgear, which is relevant both to Hunt staff and to followers. This organisation has no power to compel individuals to follow that guidance, nor to enforce any steps that we might recommend. Bearing those factors in mind, I have reviewed the matters of concern set out in paragraph 5 of the Regulation 28 Report. I have also liaised with the Cotswold Hunt - which is a Hunt which is within the membership of the MFHA - because I am aware that the Hunt has been reviewing its Risk Assessments following the death of Bonamie Armitage. My response in relation to each matter of concern (speaking on behalf of the Association) is as follows: MATTERS OF CONCERN 1. There is no mandatory requirement that all child participants in a Hunt are required to wear personal protective equipment: Response: I note that the Hunt propose to include within the Risk Assessment which relates to trail hunting activities, that all children are to wear headgear and body protectors which conform to current EU safety standards. I am prepared to issue guidance to the membership of the MFHA that this is the recommended practice for all Hunts. 2. There is no mandatory requirement that all child participants in a Hunt are required to demonstrate an established level of competence before participating in a Hunt: Response: At present the proposed Risk Assessment states that children aged 14 to 17 may ride unsupervised provided that they hold the Pony Club C Test, or an equivalent qualification, or have demonstrated their competence by previous experience. | understand that at the Inquest the Health and Safety Authority indicated that children from the age of 11 upwards would be able to ride independently if they held the C Test. In my experience, an established level of competence can be obtained through children’s Hunts and through riding whilst accompanied by a more experienced participant (often a parent). Thereafter, the level of competence is secured by experience, which is the case in many sports which carry an element of risk. Director: Tim Easby = oe There are many very competent riders who hunt with our membership and who are too young to actually take the C Test. On that basis, I would not wish to limit entry to hunting to those who are 11 or over. I am prepared to recommend to the membership that they follow the approach taken by the Cotswold Hunt to establish that young riders either have the C Test or the requisite experience to participate. 3. There is no mandatory requirement that children are supervised by adult riders when participating in a Hunt, and no ratio of adult supervisors to child riders is stipulated: Response: Many of the most talented riders engaging in hunting will be in the age bracket of 11 to 17. Some of those riders will be of an International standard for equestrian events. To that extent, it would not be necessary or desirable that riders of considerable ability and experience should require supervision from an adult who may well be less competent. In my experience, and the experience of our members, most of the occasions where unsafe riding is identified, will be amongst the adult contingent. Hunts will determine for themselves whether any formal Rules are required in relation to supervision, but I regard the view taken by the Cotswold Hunt is to be a sensible approach. It can be summarised as follows: (a) Children under 5 years of age will be on a lead rein; (b) Children aged 6 to 13 (although they may well change that to 11 given the observation above), will be supervised; and (c) Children aged 14 to 17 (again this may be altered to 11) may ride unsupervised provided that they satisfy the matters set out in 2 above. The category of children from 6 to 11 falls between the other groups. For the first group under 5 there is complete supervision. For the third group there is no supervision on the proviso that there is either a Club C Test held or sufficient experience. Within the middle group there will be extremely competent riders and everything that I have read suggests that Bonamie Armitage was in that category. The degree of supervision will therefore be variable. There may be days when a competent 10 year old requires very little supervision. There may be other days — perhaps on a different pony — where a considerable amount of supervision will be required. It is because of those variables that I do not consider that a pre-determined ratio is required. The best information available on the proficiency of both pony and rider will almost invariably come from the supervising adult. Having those supervision arrangements in the hands of those that know the child or children well, is in my view, a far safer option than an arbitrary ratio. The MFHA will obviously continue to keep issues of safety under review. Obviously the death of Bonamie Armitage was a tragedy, but accidents involving young riders in the hunting field are very rare. More frequent are the accidents involving adults which reflects the fact that following hounds across country on an undetermined route can never be entirely free of risk. Yours sincerely, —_ Director: Tim Easby
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