Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0054, written 21 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2018 |
|---|---|
| Reference | 2018-0054 |
| Deceased | Richard Phillips-Schofield |
| Coroner | David Clark |
| Coroner area | Portsmouth and South East Hampshire |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , British Cycling, Stuart Street, Manchester, M11 4DQ Anne Adams-King, Chief Executive, Welsh Cycling, Wales National Velodrome, Newport International Sport Village, Newport, South Wales, NP19 4RB. 3. Craig Brown, Chief Executive, Scottish Cycling, Sir Chris Hoy Velodrome, Emirates Arena, 1000 London Road, Glasgow, G40 3HY ycling Time Trials, League of Veteran Racing Cyclists, 6. EEE The League Internationa! 1 | CORONER lam David Clark Horsley, Senior Coroner for the Coroner area of Portsmouth and South East Hampshire. 2 | 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. 3 | INVESTIGATION and INQUEST On 14" March 2014 | commenced an investigation into the death of Richard Frederick PHILLIPS-SCHOFIELD, aged 33. The investigation concluded at the end of the inquest on 12" February 2018. The medical cause of death was head and chest injuries. The conclusion of the inquest was Richard Frederick PHILLIPS-SCHOFIELD died as a result of an accident. 4 | CIRCUMSTANCES OF THE DEATH During the afternoon of 9th March 2014, Richard Frederick PHILLIPS-SCHOFIELD was competing in a cycle race on a track at the Mountbatten Centre, Portsmouth. During the last lap of the race he fell from his cycle arid sustained unsurvivable head and chest injuries. He was taken to Queen Alexandra Hospital, Portsmouth, where at 13:30 hours on 11th March 2014, he died as a result of those injuries. The injuries were sustained due to Richard coming into contact at speed with an unyielding object after falling from his cycle. 5 | 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. — From the evidence given at the inquest, both by witnesses and a video of the race, the steps taken to halt the race after the accident were ineffectual to prevent numerous cyclists riding through the aftermath of the accident where a number of competitors, including the deceased, were lying injured. | was told in evidence that there are no formal, effective procedures in the regulations of any of the organisations controlling cycle racing in the United Kingdom for stopping a race in the event of an accident or hazard on the track. It would be left to the organisers on site to stop a race in whatever way they felt appropriate. | believe that the various national cycting organisations should consider introducing formal effective procedures for halting races which would be mandatory for all races organised under their regulations. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations 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 18" April 2018. |, 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 the Chief Coroner and to the following Interested Persons Mr PHILLIPS-SCHOFIELDs family and to Portsmouth City Council. tam 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. 21 February 2018 David/Clark Horsley ALS,
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.
+4 HSBC &)>UK
Y
Oy BRITISH
CYCLING
British Cycling
Stuart Street
Manchester M11 4DQ
T: +44 (0) 161 274 2000
F: +44 (0) 161 274 2001
britishcycling.org.uk
Mr David Clark Horsley
Area Coroner
Coroner's Court
1 Guildhall Square
Portsmouth
PO1 2GJ
17 April 2018
Dear Mr Horsley
REGULATION 28: REPORT TO PREVENT FUTURE DEATH: RICHARD PHILLIPS-
SCHOFIELD (DECEASED)
Thank you for your Report dated 22 February 2018 made under paragraph 7, schedule 5, of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013 ("Report”), which has been made following the inquest touching the death
of Richard Phillips-Schofield which was heard at Portsmouth Coroner’s Court on 5-12
February 2018.
We have set out below the joint response of British Cycling, Scottish Cycling and Welsh
Cycling to the Report addressing the matters of concern raised in the Report, namely that
there are no formal effective procedures in the regulations of any organisations controlling
cycle racing in the United Kingdom for stopping a race in the event of an accident or hazard
on the track.
British Cycling is the national governing body for cycle sport in Great Britain. Welsh Cycling
and Scottish Cycling are the governing bodies for cycle sport in Wales and Scotland
respectively and as such have jurisdiction for events taking place in Wales and Scotland.
British Cycling has agreements in place with both Welsh and Scottish Cycling to ensure that
any rules set out by Welsh and Scottish Cycling do not contravene or run counter to the
Technical Regulations of British Cycling. On this basis, British Cycling has collaborated with
both Welsh and Scottish Cycling to provide a combined response to the Report.
It should be noted that there are already a number of recognised control measures in place in
cycling to slow or stop a race, which vary depending upon the type of cycling discipline,
environment or field of play. The established procedure most commonly used across the sport
is that of a coloured flag that provides a visual signal to riders and either whistles or pistols
that provide an audible signal. All competitive events that are registered with British Cycling
have trained appointed officials (also known as commissaires) and it is the responsibility of
HSBC <> UK FONDED, 9 UK sport EONDERY © Sp Bein
The British Cycling Federation trading as ‘British Cycling’ is a company limited by Guarantee, Registered in England No. 3943494 Registered Office: British Cycling Federation, Stuart Street, Manchester M11 4DQ
«/ HSBC UK
> BRITISH
OO CYCLING
British Cycling
Stuart Street
Manchester M11 4DQ
T: +44 (0) 161 274 2000
F: +44 (0) 161 274 2001
britishcycling.org.uk
the trained commissaires to ensure that, if required, a race can be slowed or stopped
appropriately.
Prior to the incident at Mountbatten, road, track and circuit commissaires were already being
educated during their initial training in how to slow or stop a race, using the appropriate
equipment, in their given discipline and this is further reiterated in the guidance British Cycling
provides for both commissaires and event organisers. The use of such equipment is
referenced in British Cycling’s 2018 Handbook, in the Technical Regulations.
The Mountbatten Circuit
The Mountbatten circuit is a hybrid circuit and is unique in terms of both circuit length and
layout. British Cycling has specifically reviewed the procedures at Mountbatten and has
introduced some new control measures to slow or stop a race. These measures include the
use of black flags and audible equipment, such as a pistol and/or whistles, as part of this
process, in common with the procedures used within the sport. The event organisers will work
with the chief commissaire at each event to ensure the organising team and the appointed
officials understand their responsibilities to stop a race. The chief commissaire will also
provide a pre-race briefing to riders that will include specific information on how a race will be
stopped if there is an incident. These specific control measures will also be incorporated into
the standard risk assessment for the circuit.
Review of current processes
In addition to the above actions, British Cycling intends to review the current processes that
exist for events that take place on other similar length circuits or for hybrid circuits such as
Mountbatten. British Cycling will further liaise with current facility operators to review the
specific risk assessment for venues and consider any additional control measures that may
be required at the facilities. British Cycling aims to complete the review and recommend any
improvements by the end of the season, in this case September 2018.
British Cycling continue to place a high priority on risk management by ensuring that the fixed
facilities and circuits used for events are fully risk assessed by a member of its risk team, with
each circuit receiving its own tailored safety document. Any specific recommendations in the
risk assessment should be adhered to by the event officials or facility operators. This supports
safe event delivery and gives the confidence that British Cycling events are being delivered to
a high standard that is consistent across the country.
British Cycling also believes that the current procedures regarding how to slow or stop a race
can be made clearer through both additional education and training of event officials and
supplementary guidance for volunteers delivering British Cycling registered events. British
Cycling will therefore complete a thorough review of all education and training content and
associated resources for commissaires and organisers involved in the delivery of British
Cycling registered events. This will involve the introduction of new measures to improve
knowledge and understanding of how to slow or stop a race across the different cycling
HSBC <> UK FONDED @ Uk sport FONDED © Nye Setiann
The British Cycling Federation trading as ‘British Cycling’ is a company limited by Guarantee. Registered in England No. 3943494 Registered Office: British Cycling Federation, Stuart Street, Manchester M11 4DQ.
-/ HSBC UK
> BRITISH
1
OOCYCLING
British Cycling
Stuart Street
Manchester M11 4DQ
T: +44 (0) 161 274 2000
F: +44 (0) 161 274 2001
britishcycling.org.uk
disciplines. For example, it will include the use of scenario based activity and better reference
material in educational resources. British Cycling also intends to communicate with existing
circuit and track commissaires to ensure that as part of the rider pre-race briefing they
communicate how a race will be slowed or stopped. The organisation will also communicate
any revised education and training content related to how to slow or stop a race to existing
commissaires at British Cycling’s regional commissaire conferences that take place in
February each year.
We trust that the above addresses the matters of concern raised in the Report; however,
should further information be required please do not hesitate to contact us.
Yours sincerely
Signed for and on behalf of
BRITISH CYCLING YY BRITIS
(The British Cycling Federation) or Barish
by the following duly authorised signatory v)
Julie Harrington
Chief Executive
» |
i |
Signature:
Signed for and on behalf of wt
SCOTTISH CYCLING oe
ase
(Scottish Cyclists’ Union) <coirsH
by the following duly authorised signatory CYCLING
Craig Burn
Chief Executive
Signature :
Ze Law|
HSBC <)> UK LOTTERY J uk sport FONDED. (8 SY Reino
‘The British Cycling Federation trading as ‘British Cycling’ is a company limited by Guarantee. Registered in Fngland No. 3943494 Registered Office: British Cycling Federation, Stuart Street, Manchester M11 4DQ.
Signed for and on behalf of
WELSH CYCLING
(Welsh Cycling Union)
by the following duly authorised signatory
Anne Adams-King
Chief Executive
Signature:
QL Adour leuncy
HSBC > UK
LSUEERY < uk sport
\y HSBC. UK
BRITISH
OOCYCLING
British Cycling
Stuart Street
Manchester M11 4DQ
T: +44 (0) 161 274 2000
F: +44 (0) 161 274 2001
britishcycling.org.uk
” peicio cymAU
yy WELSH CYCLING
FUNDED © AY Eile
The British Cycling Federation trading as ‘British Cycling’ is a company limited by Guarantee. Registered in England No. 3943494 Registered Office: British Cycling Federation, Stuart Street, Manchester M11 4DQ
See every Prevention of Future Deaths report matching David Clark, 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.