Prevention of Future Deaths reports · 2020

Colin North

Regulation 28 report to prevent future deaths, reference 2020-0003, written 9 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Jan 2020
Reference2020-0003
DeceasedColin North
CoronerLouise Hunt
Coroner areaBirmingham and Solihull
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:   

Incarace 

1. 
2.  ORCi 

1 

CORONER 

I am Mrs Louise Hunt, HM Senior Coroner for Birmingham and Solihull 

2 

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 26/11/2019 I commenced an investigation into the death of Colin Alan North. The investigation has 
not yet concluded however following receipt of the TV footage of this incident I was extremely 
concerned about the safety of Stock Car racing events. I understand further racing events are being 
staged and I felt it necessary to send the report to prevent future deaths before the conclusion of the 
inquest.  

4 

CIRCUMSTANCES OF THE DEATH 
Colin North was attending a Stock Car racing event at Birmingham Wheels venue being run by Incarace 
on 16/11/19. He attended on behalf of his employer to present trophies after races. Following the 
conclusion of race 3, Mr North walked onto the track through the vehicle gate and walked along the track 
towards the presentation area which was in the middle of the track. At the time all the race vehicles 
were still on the track – some doing “doughnuts” and various recovery vehicles were entering the track 
to remove broken down or damaged vehicle. Two of the recovery vehicles were large tractors. The track 
has many pedestrians walking round whilst all these vehicles are moving onto the track and there is no 
control of pedestrians on the track and no pedestrian walk route.  

As Mr North walks around the track he moves past a recovery vehicle parked on his right hand side and is 
then hit from behind by a large tractor being driven onto the circuit. He died at the scene. 

Following a post mortem the medical cause of death was determined to be: 

1a. Multiple injuries  
1b Road traffic collision 

5 

CORONER’S CONCERNS 

During the course of the hearing 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.  The TV recording of the event shows that as soon as the race is concluded the gate to the only 
entry and exit point is opened. Pedestrians (in using this term I include those working at the 
event and others) and several recovery vehicles then come through the gate. At the same time 
Stock Cars remain on the track some undertaking “doughnuts”. There are many pedestrians 
moving around the track area whilst large recovery vehicles are moving, some at speed, onto 
the track. There is a complete absence of control of any pedestrians onto and those already on 
the track. There is no pedestrian walkway on the track and no designated pedestrian safe area. 
There is a complete lack of awareness of the risk to pedestrians on the track who are in very 
close proximity to large recovery vehicles. Urgent action is required to review when and how 
pedestrians should be allowed on the race track at any time during a race event.  

2.  Urgent action is required to ensure pedestrians on the track have clear protected walkways and 

safe areas away from large recovery vehicles. 

3.  Urgent action is required to review the risk assessment document to ensure it adequately 

protects any pedestrians that need to be on the track. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  Urgent action is required to review the prize giving procedure and to consider moving this to the 
“Public Area” as there appears to be no need for it to be undertaken in the middle of the track 
amongst moving vehicles. 

5.  Urgent action is required to consider the safety of staff working during the races and whether 

they should remain on the track given that they are completely unprotected should a vehicle in 
the race lose control. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the power to take 
such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by  
5 March 2020. I, 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

The Family 

 
 
 
  Birmingham Wheels 
  Birmingham City Council 
  WMP  
 
Teng Tools Ltd 
  Brisca Formula 1 

I 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. 

9 

09/01/2020 

Signature 

Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull

Responses

2 responses 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 Incarace Ltd (PDF)
PLEXUS

Louise Hunt Our ref: RMS-CAT.001- 27

HM Coroner Your ref: 132886 — Colin North — 16" November
Coroner's Office 2019

50 Newton Street Date: 3 March 2020

Birmingham

B4 6NE E:
T:

Dear Sirs

Regulation 28 Report to Prevent Future Deaths
Relating to the death of Colin North - 16" November 2019

| write further to the above Regulation 28 Report issued by Her Majesty’s Coroner Louise Hunt on 9%
January 2020 to our client, Incarace Ltd.

At Section 5 of the Report, the Coroner set out 5 areas of concern, which are addressed in turn
below:

1. Urgent action is required to review when and how pedestrians should be allowed on the
race track at any time during a race event.

Response:
The revised Risk Assessment prohibits any pedestrians on the track during a race event.

The drivers of race cars are not permitted to leave their vehicles on the track, other than in the event
of an emergency such as a fire or if authorised to do so by the Clerk of the Course.

There are trained staff such as the Clerk of the Course, Marshals, Fire Marshals, licenced breakdown
drivers and First Aiders located on the infield (but not the track area) in designated areas during a
race. The staff have defined roles and responsibilities which includes the safety of drivers during a
race and in the event of an incident.

The only other officials authorised to have access to a designated area on the infield during a race are
the ORCi licenced photographers. They are not permitted onto the track at any time when there are
moving vehicles.

Plexus Law
Josephs Well | Hanover Walk | Leeds] LS3 1AB
DX 716926 LEEDS 39 | T: 01134 681600 | F: 0113 468 1601 | www.plexuslaw.co.uk

Plexus Legal LLP (trading as Pleas and Plexus Law) is a limited liability partnership registered in England & Wales with registration number OC 416421 and with its registered office address at Josephs Well, Hanover Walk, Leeds, LS3 1AB.
Plexus Legal LLP is a firm of solicitors regulated and authorised by the Solicitors Regulatory Authority (SRA ID No. 638317) whose professional rules can be accessed at wwrw.sta.org.uk. A list of members is available for inspection at our
registered office address. The term ‘partner’, and ‘associate partner’ includes a member of Plexts Legal LLP or an employee or consultant of equivalent or senior standing and it may include non-solicitors or non-lawyers. For further
information on how we handle your personal data, please see our Privacy Staternent which is available at: http://plexuslaw.co.uk/legal-notices/privacy-statement/

In the event of a recovery operation being required, there are two defined procedures depending
upon whether a stoppage has occurred during or at the end of a race.

During a race stoppage (for example, following a multi vehicle collision), driver(s) may leave their
vehicles when all vehicles are stationary and authorised by the Clerk of the Course. In the event that,
a recovery of a vehicle is required, the recovery vehicle will park next to the vehicle in question and
when permitted to do so by the Clerk of the Course, the driver will then exit the vehicle to assist the
recovery driver if necessary and then re-enter the race vehicle and be driven to the infield where the
driver will remain in the race car and with full Personal Protective Equipment continued to be worn
until the end of the race. Alternatively, the driver will be escorted by the Clerk to the pit gate and
off the track. If this is not possible, then the procedure for vehicle recovery is also applicable at the
end of a race. No driver is permitted to enter the track at any time without authorisation.

In any other potential circumstances where a driver may require access to/from a vehicle at any
other time, they may be driven to a recovery vehicle, or escorted to the car by an official in full —
body high-viz clothing. Any official who enters the track and infield areas will be wearing full body
high-viz clothing as a mandatory requirement.

At the end of a race, any drivers proceeding onto or off the track are not permitted to do so on foot.
The Recovery Vehicles are only permitted to enter the track on the instruction of the Clerk of the

Course through the pit gate and only when the Clerk is satisfied that there is no pedestrian
movement on the track.

Other staff and officials such as sponsors’ or promoters are only allowed to enter the track when
there is no vehicle movement. This is overseen by the Clerk of the Course and escorted by one of the
trained officials.

2. Urgent action is required to ensure pedestrians on the track have clear protected walkways
and safe areas away from large recovery vehicles

Response:

The prohibition on pedestrians on the track while there are moving vehicles deems it unnecessary for
a designated or protected walkway.

3. Urgent action is required to review the Risk Assessment document to ensure it
adequately protects any pedestrians that need to be on the track
Response:
See under 1 above.
4. Urgent action is required to review the prize giving procedure and to consider moving this
to the “Public Area” as there appears to be no need for it to be undertaken in the middle of

the track amongst moving vehicles

Response:

The prize giving is now undertaken when there are no moving vehicles on the track.

2 of 3

5. Urgent action is required to consider the safety of staff working during the races and
whether they should remain on the track given that they are completely unprotected
should a vehicle in the race lose control

Response:
There are no staff permitted on the track area during a race.

As stated above, there are officials and staff who have specific roles and responsibilities during a race
on the infield area and include roles that are crucial to the safety management of a race event. They
are positioned in designated areas that are pre- determined on a site by site basis. It requires each
site to be assessed and then a decision made regarding the location of the officials during a race.

The official staff are in radio contact with each other and with the race controller in the control box.
The Clerk of the Course and senior steward ensure that all staff and officials are in the correct
designated areas.

Race events are always covered by professional medical personnel — either from the ambulance
service or recognised first aid organisations. These personnel are essential and their location on the
infield is preferable as it affords them the quickest and safest access to any incident on the track.
They are in a position where they can fully observe an event and access the track, if required on foot.

If there are any questions or queries to the responses, please do not hesitate to contact us.

Yours faithfully

\
\

Myo esis
Plexus Law

This document is classified as CONFIDENTIAL

30f3
Response from Orci Redacted 1 (PDF)
OLM  King's House, 42 King Street West, Manchester M3 2NU 

T +44 (0)I61  236 2002  F +44 (0)161  832 7956  DX 14302 MANCHESTER  I  blmlaw.com 

Contact: 

Direct Line: 
Email: 

Our Ref :HCR/149492-275 

5 March 2020 

Mrs Louise Hunt 
Her Majesty's Coroner for the City of Birmingham and the 
Borough of Solihull, 
Coroner's Court, 
50 Newton Street, 
Birmingham, 
B4 6NE 

Dear Madam 

Regulation 28 Report to Prevent Future Deaths 

We  are  responding on behalf of the ORCi to the Regulation 28 Report you issued  dated 9" January 2020, 
following the concerns you raised at the PIRH  of the Inquest touching the death of Colin  North which took 
place on 8" January 2020. 

We respond herein to the matters of concern,  listed 1-5 in  Section 5  of the Report,  and in compliance with 
Section 7 of the Report to respond setting out "details of action taken or proposed to be taken, setting out the 
timetable for action. Alternatively to explain why no action is proposed'. 

On behalf of the ORCi, we respond as follows.  Please note that the measures set out below address your five 
matters of concern taken together. 

•  Upon receipt of the Regulation 28 Report on 9" January 2020,  the ORCi distributed the Report to all 
its members on the same day and advised that these concerns had been raised as a priority by HM 
Coroner. 

•  Prior to this,  interim control measures (attached) had been produced by the ORCi in conjunction with 
Incarace and Spedeworth following the tragic death of Colin North and these were sent to all  ORCi 
members  on or around 25" November 2019. Amongst a  global  review of procedures,  these sought 
to address  the matters of pedestrian / vehicle segregation which were raised in your Regulation  28 
Report. We  invite  your attention  to the third  to eighth  bullet points  within these Interim Control 
Measures which identify the sequence to be followed at the end of a race,  requiring recovery vehicles 
only to enter the track once all pedestrians have exited the race arena, thereby safeguarding them. 

•  The ORCi recognises that,  as identified by your Report, appropriate control  measures need to be kept 
under review to ensure  practices  are  safe.  We  can  confirm that we  are  aware  that Incarace  are 
continuing to undertake a  process of consultation with experts and professionals to produce a  Risk 
Assessment,  including the appropriate control  measures, for application across the industry.  Once this 

BLM  is a trading name of Berrymans Lace Mawer LLP, a limited liability partnership registered in England under number OC340981, authorised and regulated by the Solicitors  Regulation 
Authority and the Law Society of Scotland. The registered office is at King's House, 42 King Street West, Manchester M3 2NU where a list of members is available for inspection. BLM Ireland is 
affiliated to Berrymans Lace Mawer LLP and the partners  are either members or employees of Berrymans  Lace Mawer LLP.  Partners of Berrymans Lace Mawer LLP are members  or employees 
of Berrymans  Lace Mawer LL P and the use of the term "partner" should  not be  construed  as  indicating that the individuals  so designated  have  entered  into partnership  (within  the meaning 
of the Partnership Act 1890) with all  or any of the individuals so designated or with any individuals and Berrymans Lace Mawer LLP Berrymans Lace Mawer LLP is certified to Information 
Security Standard ISO 2700 I  (BSI  certificate IS589484) Quality Assurance Standard ISO 900 I  (SGS certificate GB  13/90471) and Lexcel, the Law Society's Practice Management Standard. 

 
 
 document is finalised,  and to allow time to enable the ORCi to adequately consult,  review and cascade 
recommendations  to  its  members  for  their  considerations  and  individual  implementation,  we 

anticipate that a final advisory document will be in place by 19"May 202O, in time for the next PIRH. 

We  assure you that the  ORCi are  treating  this  incident with  the  highest  level  of importance  across its 
membership and are  continuing  to  liaise  and  consult with its members.  We  shall  keep you updated  on 
progress up to 19" May 2020. 

Partner 
BLM 

2 

Confidential - 1 
50422984vl 

 
 SPEDEWORTH MOTORSPORTS 
Spedeworth House Hollybush Industrial Park, 
Hollybush Lane, Aldershot, 
Hants, GU11 2PX 
Tel: 01252 322 920 
Email: info@spedeworth.co.uk 

Friday 22" November 2019 

Interim control measures for forthcoming events at Spedeworth International (Southern) Ltd & 

Spedeworth (East Anglia) Ltd. 

As of the above date and until a review and update of the 2019 risk assessments for the tracks 

registered to the above companies is completed the following interim control measures will be applied 

to operate alongside the current risk assessments dated January 2019. 

•  Unless specified within section 16 of the risk assessments under the existing control measures 

all other persons will not be permitted access to the race arena. 

•  At the conclusion of a race the pit gate will remain closed until all race cars have stopped. 

•  Once the pit gate is open any persons who are within the current existing control measures may 

enter the arena. 

•  Until the pit gate area is cleared of persons except for the pit gate staff vehicles will not be 

permitted through the gate. 

•  Once the clerk of the course is satisfied that persons within the race arena are within 

satisfactory positions e.g. drivers are with their cars; the drivable cars will be permitted to leave 

the race arena. 

•  This will be followed by the recovery vehicles then being permitted into the race arena to assist 

the undrivable cars. 

•  Race drivers will be reminded at the drivers briefing about remaining in their cars whilst within 

the race arena unless there is an emergency e.g. drivers car is on fire. 

•  All other persons who are under the existing control measures within section 16 of the January 

2019 risk assessment(s) will be informed of the interim control measures at a staff briefing 

which will take place prior to the commencement of the first race. 

•  Section 15 of the risk assessments 'Car to person impact- pits' details the speed limit in the pit 

area is 5mph.  Drivers who are found to be speeding will be reported to the Safety Officer. The 

safety officer will then take the appropriate action which can be issued via a verbal warning upto 

the driver being banned which would be reported to the ORCi and the driver notified by letter. 

iii9iii0er 64±i519348 %I%I2B] 98#Mg 0UCL«a] @> sans WENwa» 

 TORSP ORT5 

SPEDEWORTH MOTORSPORTS 
Spedeworth House Hollybush Industrial Park, 
Hollybush Lane, Aldershot, 
Hants, GUll 2PX 
Tel: 01252 322 920 
Email: info@spedeworth.co.uk 

•  A one-way system will be operated between the outer Pit Gate to the actual track Pit Gate. Cars 

are marshalled so the cars move in, or out, but not both ways at the same time. The pit marshal 
and pit gate marshal will communicate via hand signals or radios to allow this process to 

happen. 

•  Drivers and staff will be informed of these points during the respective briefings.

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