Prevention of Future Deaths reports · 2020
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 report | 9 Jan 2020 |
|---|---|
| Reference | 2020-0003 |
| Deceased | Colin North |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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
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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