Prevention of Future Deaths reports · 2017

Bonamie Armitage

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 report25 May 2017
Reference2017-0170
DeceasedBonamie Armitage
CoronerKaty Skerrett
Coroner areaGloucestershire
CategoryChild Death (from 2015) · Other 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.

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

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 Mfh Association (PDF)
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

Related reports

Other reports by Katy Skerrett

See all →

More reports categorised “Child Death (from 2015)”

See all →

Track Child Death (from 2015)

See every Prevention of Future Deaths report matching Child Death (from 2015), 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.