Elliot Burton

30 June 2021 

HM Senior Coroner Kevin McLoughlin 
Her Majesty's Coroner's Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Sir 

Regulation 28 report - Elliot Peter Burton 

DATEDATDATE 

Foresight Group ("Foresight") write in relation to the above Inquest heard on 30 April 2021 following 
the sad death of Elliot Peter Burton on 29 July 2019. In particular, we seek to address the concerns 
set out in the Regulation 28 report dated 30 April 2021.  We are grateful to you for drawing these 
concerns to our attention.  

This was indeed a very tragic event and our thoughts and deepest sympathies go out to Elliot's 
family and friends.  

We were not granted Interested Person status and so could not address the Inquest directly but we 
understand the evidence led to some concerns about: 

1. 
2. 
3.  
4. 
5. 

the site location and its site security; 
historic trespass incidents; 
the safety measures around the water in the facility;  
access to the site via the weir across the River Calder; and  
action to be taken to reduce the risk of harm of trespass by children.  

Before turning to these concerns, we wish to set out the factual background which we hope will 
provide some explanation as the reasons for our response.  

 
 
 
 
 
 
 
 
 
 
 Background  

Foresight is an infrastructure and private equity investment management company with extensive 
portfolios across a number of funds.  In the vast majority of companies in respect of which we advise 
we appoint a Non-Executive Director, to enhance and protect our client's/the funds' investment. 

In line with our normal practice 
was appointed to the board of Yorkshire 
Hydropower Limited ("YHL") in the role of Non-Executive Director.  He was, of course, a witness in 
relation to the inquest and is a Senior Portfolio Executive employed by our business with extensive 
experience in renewable energy. In terms of the relationship between Foresight and YHL, we act in 
our capacity as investment advisors, making business recommendations to our client, which is an 
institutional investor,  and the ultimate owner of YHL since 19 July 2019 (i.e. very shortly before the 
fatal accident). We do not own or have any financial stake in YHL, nor do we have a direct 
contractual relationship with the business itself.   

The nature of our activities pertaining to YHL 

YHL operated Kirkthorpe Hydropower Station.  We are contracted to provide Investment Advisory 
Services to the aforementioned institutional investor. Our role includes ensuring and monitoring 
that there are appropriate contractual relationships and competent advisors in place to support the 
business, from a financial perspective.  This obligation does not, however, include day to day 
management of YHL or its parent company (YHL Holdings Limited)'s affairs; or advice relating to 
health and safety matters.  Instead, as above, we provide Non-Executive Directors with relevant 
experience, who fulfil their roles independently and impartially, as they are required to by law. 

We understand that we were not at any stage suggested to be a party to this Inquest. Foresight's 
links with YHL at the relevant time derived from its contract with YHL's ultimate parent and the 
employment of Mr Hardy, both of which are addressed below. 

As a responsible company, and in light of your concerns raised in the Regulation 28 report, we have 
reviewed the recordings of the evidence given to identify any steps required on Foresight's part.  
However we have identified nothing indicating that Foresight had control of YHL's operations, or 
that 

 role with Foresight dictated or constrained his actions as a director of YHL. 

Such operational decisions were, and are, decisions for YHL to make, entirely independent of 
Foresight, as these companies have separate legal personas.  Any person holding a director role by 
virtue of Foresight's Investment Advisory Services contract is an employee of Foresight's business 
and a director of YHL. Any such individual is fulfilling two distinct roles, which are clearly delineated 
and do not afford Foresight any control over YHL, including how any director should have exercised 
their discretion as a director. Clearly any director has a statutory obligation to act only in the best 
interests of the company and not to vote on matters in which they had a conflict of interest.   

 
 
 
 Foresight does routinely provide training to Directors, and those who may become Directors, on 
their duties and expectations in the role of Director on project company boards. This training is 
provided by third party training providers and covers legal, commercial and operational aspects of 
Directors' duties. It also includes training on specific duties Directors have in relation to health and 
safety matters, which is recognised by the Institution of Occupational Health and Safety (IOSH).  This 
training is intended to equip those who may fulfil a statutory role on their obligations so that they 
can discharge these responsibly. 

Although  we are extremely saddened by Mr Burton's death, we feel obliged to respectfully drawn 
the factual situation to your attention so as to assuage any concerns over the fact that it is YHL who 
are taking the steps to ensure there is no repetition of this tragic accident.  As set out above, we 
cannot and do not exercise any control over YHL's affairs. 

Despite the previous paragraph, Foresight treats this situation with the utmost seriousness and 
gravity.  We have taken up the matter with YHL in order to establish what steps it has taken and 
proposes to take, in order to be assured that appropriate action has been taken. 

We have now had the opportunity to review the draft response prepared on behalf of YHL and we 
fully endorse and support the proposed measures they have outlined in that document.  For 
completeness we note that those actions include: - 

(A) 

(B) 

(C) 

(D) 

(E) 

(F) 

(G) 

(H) 

Additional fence returns and mesh infills to deter climbing/access from the land side 
of the Facility 

Additional warning signs  

Enhanced  CCTV  system  (with  greatly  improved  coverage  and  resolution),  actively 
monitored at all times. 

Improved PA system to enable loud warnings to be issued remotely on detection of 
trespassers. 

Various measures to block off routes within the Facility, through the use of barriers 
and secure gates. 

Covering of some channels where practicable to do so. 

Ongoing liaison with the local emergency services. 

Daily manned security presence during summer months from 10am to 8pm.  

We believe that the security of the site will be greatly enhanced by these measures, and by any 
steps taken by both the Local Authority and the Canal and Rivers Trust. 

 
 
 
 
 
 We do hope that this letter is self-explanatory but would be happy to provide further information if 
that would be of assistance. 

Yours faithfully 

Partner & Chief Investment Officer 
Foresight Group

v/akefieldcouncii

po Communities, Environment and

Date: 17 May 2021 Service Director: Property, Facilities, Hon and Sate
. . Corporate Facilities Manager, EN
Kevin McLoughlin Wakefield Council
Coroner's Office and Court Wakefield One
71 Northgate Burton Street
WF1 3BS WE

Typetalk calls welcome

Dear Mr Mcloughin

Re:- Inquest touching the death of Elliot Peter BURTON, (deceased)

| refer to your letter dated 30th April 2021, and the request to provide a response to the
Regulation 28 Report to Prevent Future Deaths.

Please find enclosed what | hope is a comprehensive report in full response to the concerns
you have raised and recorded in respect of the above case.

If you require any further information or detail please do not hesitate to contact me.

Yours sincerely

orporate Facilities Manager

Enc.

CONFIDENTIAL

TO Kevin McLoughlin
OFFICE OF THE SENIOR CORONER
Coroner's Office and Court
71 Northgate
Wakefield WF1 3BS

FROM HE Corporate Facilities Management Manager
Property, Facilities, Health and Safety
Wakefield Council

RE Inquest touching the death of Elliot Peter BURTON, (deceased)
Response to Regulation 28 Report to Prevent Future Deaths

DATE 17 May 2021

SS OS

1.0 Purpose of the Report

1.1 To provide a comprehensive response to the Senior Coroner and address his
concerns arising from the Inquest touching the death of Elliot Peter BURTON,
(deceased).

1.2 The following report will update on all the safety actions taken to date by
Wakefield Council in the location of the Kirkthorpe Weir, the Yorkshire Hydro
Plant and the surrounding areas. It is intended to provide detailed assurances
of the safety work already undertaken, the current and ongoing safety plans
and projects in evolution.

1.3 The current strategy and plans are to undertake comprehensive physical
works and construction projects. This is with aim to design and build robust
physical barriers in the challenging and changing environments on the
embankments adjacent the Kirkthorpe Weir. The result will be to prevent as
far as is reasonably practicable, trespass to the Yorkshire Hydro Plant and
access to the Weir on both sides of the river in this locale. This project is
working in Partnership with the Yorkshire Hydro Plant — Foresight Group
(YHP) and the Canals and River Trust (CRT). Wakefield Council have also
been working in close liaison with the Health and Safety Executive from the
outset of this case.

2.0 Background

2.1. Wakefield Council has taken a significant lead in formulating a safety strategy
for the area surrounding Kirkthorpe Weir. The Council owns the land on both
sides of the river at this point. The west bank is part of the area known as the
Southern Washlands and has nearby fishing lakes, country side walks and
public footpaths. The east bank is the location of the YHP Plant. The plant
owners lease the land, but have full responsibility as occupier for their own
construction, operations and buildings within this demise. This includes their
security and perimeter management. CRT have ownership of approximately
half of the Victorian weir construct. The council own the other half - but CRT
take responsibility for its upkeep and general maintenance. The waterway

2.2

2.3

2.4

2.5

2.6

2.7

itself is the responsibility of CRT. Notwithstanding the complexities of
ownership and responsibility, all parties have been cooperating to improve
safety of the whole area since 2019 in respect of this case.

In early August 2019 shortly after the tragic events of Elliot Burton’s death, a
site inspection by Wakefield Council Officers, was undertaken to determine
what immediate safety measures could be taken to prevent further
occurrences or anything that posed an immediate danger to the public. At this
stage no details of the death itself or exact location had been released. Both
sides of the river were inspected along with the perimeter of the YHP plant.

On the 14 August the HSE met with colleagues from YHP and CRT. This was
to look mainly at the west bank of the river. This is where it was stated was
the location that Elliot traversed the weir to eventually gain access to the YHP
plant on the east bank.

It was apparent from both visits that the west bank area was frequented as a
popular spot to swim and fish by members of the public. It was agreed that
some immediate measures could be taken to highlight the dangers of the fast
flowing water. The Council and YHP over the coming weeks instigated the
updating and adding of additional safety signage. This included warning of the
dangers of the water, fall from heights and the Weir itself. Many of these signs
were promptly vandalised and removed by persons unknown. The Council
have been actively checking and replacing these since the incident. The
signage has evolved to larger and more prominent notifications, and we have
added the “What 3 Words” location data to each. This is a system the
emergency services use to locate accurately anyone in distress in remote
areas. There are several signs being replaced again this month due to
vandalism.

In January 2020 the Council revised the risk assessment for the west bank.
This resulted in not only replacing numerous signs, but we also erected
several new fenced barriers in attempt to improve safety and restricting
access to the Weir and waters’ edge. The fencing construction at that time
was limited. This area is heavy in vegetation, trees and swathes of wild
Japanese knotweed. It has therefore been a very challenging environment to
place physica! barriers successfully.

During this time, consultation with all 3 parties and the HSE were looking at
the more challenging aspect of preventing trespass to YHP from the river and
particularly gaining access by members of the public traversing the Weir.
Several engineering solutions were considered each with their own difficulties
with construction in a fast flowing river. Some solutions were dismissed. They
may have prevented trespass, but their inherent design upon scrutiny,
potentially caused other foreseeable risks. Other solutions may not have
withstood flood waters.

Further challenges to enable physical measures more quickly has been that
the Weir construct itself is a listed structure. As such conservation planning
consents and design have to consider Historic England Planning approvals.
Ecological factors have also had to be considered in terms of the fish passes
on the Weir for example, and DEFRA generally. This impacts on the final

2.8

3.0
3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

designs — which in turn have to be robust enough to withstand the extremes of
the river, and not impact on the natural habitat of the surround areas.

Despite all the challenges, safety and the prevention of future deaths has
been a priority throughout.

Current and Next Steps

In recognition of the demanding challenges to construct suitably designed
physical barriers on both sides of the river in a short time, the Council has
been undertaking regular manned security inspections to discourage anyone
entering the water, and highlighting the dangers. This is undertaken
Specifically on hot weather days, holidays and alike as well as periodically
through each month. This regime is recorded and has been in place since the
summer of 2020. This security detail has also been extended to other still and
flowing water body sites across the district where public have regular access.

There are 3 Phases of work associated with the safety works at Kirkthorpe
Weir. Phase 1 has been the measures taken to date as noted. Phase 2 isa
joint approach to design a suitable physical barrier to the perimeter of the
YHP site on the river side. The concept of this has been in the feasibility and
design stages since June 2020, with the first designs suggested in October
2020.

As noted several designs proved potentially unsuitable. New impetus and
revisions were presented by January 2021. The final design being approved
to progress to detailed design in March 2021.

This final detail is expected to progress through all planning approvals and
consents by the end of May 2021.

Pending the planning approvals, procurement, manufacture and finally
construction will then begin. All of this to completion is expected to take until
October 2021. Caveats to the construction phase will be subject to
environment conditions of the river (i.e. not in flood). The timeline could be
shorter but allows for the anticipated planning approvals taking up to 60 days,
which is the norm. We are of course pushing to expedite consents as soon as
is possible.

Phase 3 is running in parallel to Phase 2. This is a solely Council led initiative,
the concept of which was supported by the HSE. This is to add further fenced
protection to the west bank of the river based on our revised risk assessment
of the site.

A feasibility over the last 3 months has been underway to look at how we can
add approximately 300m of fenced deterrent. This will improve safety, deter
further and assist in preventing access to the Weir. This had to consider and
overcome the challenges to undertake heavy construction of the mostly
inaccessible terrain, and without detracting from the country side walk and
ecological factors as noted.

A design option has been approved to progress and will include more robust
Signage. This will include information boards on the conservation of the area,
and the purpose of the Hydro Plant opposite. We intend to install a new and a
safe viewing platform of the Weir - which is intended to be both informative
and provide safety awareness. This will assist in making the usual access

area to the Weir and river at this point as impassable as much as is possible,
but also provide a controlled beauty spot viewing point for the countryside
walk. This we feel will make the area more of a managed outdoor space and
reduce the unauthorised access to the river itself.

3.9 The design and procurement of this fence and construct is underway and we
anticipate completion of this element to be in mid July 2021

4.0 Conclusion

4.1 After the tragedy that resulted in the death of Elliott Burton, Wakefield Council
has been actively pursuing safety measures to prevent further deaths at the
location of the Kirkthorpe Weir since August 2019. We have worked closely
with the HSE throughout and all the associated parties invoived. We have
taken a lead to progress new and improved safety measures on both sides of
the river. These endeavours are not without significant challenges due to the
physical locale and natural elements to contend with. We are however
confident that the schemes we are aiming to complete over the coming
months will reduce the risk of recurrence as much as is possible. After the
construction phases are complete we are planning several reviews and further
feasibilities — to ascertain if the measures we have implemented are as
effective as anticipated or if more can be achieved.

The Council are also linking its current still water body health and safety
policies and procedures, to other areas of flowing water within the district.
This is to look at where we can improve safety at other potential hazardous
sites, with a consistent approach to water safety. This is ongoing and when
complete, recommendations will be made to the Corporate Management
Team for any rectification or interventions we may need to implement to
improve safety.

| a Facilities Manager

Yorkshire Hydropower Limited

HM Senior Coroner Kevin McLoughlin 
Her Majesty's Coroner's Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

30 June 2021 

Dear HM Senior Coroner Kevin McLoughlin 

 Regulation 28 Report 

I write on behalf of Yorkshire Hydropower Limited  ("YHL") in response to your Regulation 28 report dated 30 
April 2021 regarding the death of Elliot Peter Burton at the Kirkthorpe Hydropower Facility on 29 July 2019. 

I would like to begin by, once again, expressing my condolences to Elliot's family and my sorrow for their loss.  

The design, planning and construction of Kirkthorpe Hydropower Plant (the "Facility") was concerned with the 
risks associated with unauthorised access into it. Since the Facility came into our control, we have implemented 
a wide range of further measures with the aim of reducing and preventing unauthorised access, but recognise 
that the issues present an ongoing challenge.  

Present measures include physical deterrents (perimeter fencing, warning signs, CCTV, internal barriers, gates 
and covers), to community engagement through the local police (to educate and raise awareness).   

The Facility requires open access to the river, a number of deep-water channels and pools for its operation and 
systems to reduce debris blockage and ensure its safe removal. As such, steps to further secure and/or cover 
hazards have to be carefully considered in light of other risks that they may introduce.  

In response to the evidence heard at the inquest and your comments, a further detailed review of the known 
routes taken by trespassers has been undertaken, with the assistance of an external health and safety advisor.  

Turning to the specifics of the Regulation 28 report, I respond to the detailed points raised in section 5. 

1. 

1.1 

1.2 

1.3 

Response to Paragraph (1)  

The Facility was designed to be unmanned. It does not need workers present for operation, which can 
be  monitored  and  controlled  remotely.  However,  contractors  are  on  site  at  least  3  times  a  week  to 
undertake checks and routine maintenance.  

As set  out  in evidence before the inquest, public safety and  site security is  aided  by extensive CCTV 
which is monitored by Servo, our security contractors, who can communicate directly via the site PA 
system and also will make reports to the Police and relevant key holders.  

We are currently trialling having a  manned security  presence on site between the hours of 10am to 
8pm, 7 days a week for the summer months. Primarily the guard is a deterrent. The guard will be limited 
in challenging trespassers, for example they will not be able to physically remove them from the Facility. 

Company no. 09076541, C/O RES White Limited, Beaufort Court, Egg Farm Lane, Kings Langley, WD4 8LR 

Yorkshire Hydropower Limited 

 
 
 
 
 
 
 Yorkshire Hydropower Limited 

1.4 

2. 

2.1 

2.2 

2.3 

3. 

3.1 

3.2 

3.3 

We will review the effectiveness of this at the end of the summer. This review will include consideration 
of any interactions between the guard and potential or actual trespassers, the personal safety of the 
guard, whether trespass was deterred and/or incidents prevented and whether the times were aligned 
with the periods of activity in the locality. The effectiveness and/or necessity of having such a security 
presence  will  also  be  viewed  in  the  context  of  the  other  measures  being  implemented,  these  are 
discussed in response to your other paragraphs below. 

Response to Paragraph (2)  

YHL was subject  to a share sale which  completed a  week  prior to Elliot's tragic death. Following  the 
tragedy, all reports were requested from the incumbent security contractors. These reports informed 
the  measures  which  the  board  then undertook.  However, it  was  apparent  from  the  evidence  at  the 
inquest that a full record had not been provided.  

We recognise that incidents of trespass have been ongoing for some time. Although from a review of 
all the records the method of entry across the weir was not previously used until the weekend of Elliot's 
death. The challenges of traversing 90 metres across the weir before climbing over the sluice gates and 
up and into the Facility meant that this was not a route of access which had previously been anticipated.  
As described below we have engaged with Wakefield Metropolitan District Council ("WMDC") and Canal 
and River Trust ("CRT") as the relevant landowners to identify and implement practicable measures to 
deter access along this route.  

In  relation  to  access  from  the  landside  perimeter,  we  have  added  further  fence  panel  returns  and 
signage,  we  have  also  now  had  expert  advice  as  to  the  use  of  galvanised  metal  spiked  fans.  Where 
practicable these will be used to deter persons from climbing around the edge of perimeter fence panels 
where they open on to the river and accessing ledges within the Facility. The objective is to make access 
difficult and unattractive to the Facility as a whole, and within it in relation to those areas where there 
are drops to deep and potentially fast flowing water. However, these measures must not create debris 
traps that import significant risk for those required to then remove debris and maintain the structures. 

Response to Paragraph (3)  

On  entry  to  the  Facility,  there  are  a  number  of  uncovered  channels.  These  comprise  the  screening 
channel,  outlet  channel,  fish  pass  and  eel  pass.  There  exists  edge  protection  in  the  form  of  timber 
fencing and metal railing in areas where those working in the Facility have to walk. This edge protection 
is designed to stop the accidental passage of persons into an area of danger, it is not effective at stopping 
someone who deliberately ignores it, placing themselves in danger. 

The  use  of  fences  and  barriers  within  the  Facility,  as  well  as  the  covering  of  channels  has  to  be 
considered in the context of debris entrapment and critically, access for those removing it.  The force of 
the river and the substantial debris that collects can and has caused damage to the Facility, this is one 
of the major operational concerns in this dynamic environment. 

The  size  of  the  outlet  channel  makes  any  proposal  to  cover  it  with  decking,  steel  or  other  material, 
difficult to safely install and maintain (the outlet channel cannot be readily drained). Maintenance will 
bring several operational issues, particularly around the issue of debris which will, in flood conditions, 
be deposited on top of the decking bringing with it an uncertain loading regime and a requirement to 
remove it. Such removal would require workers to have to venture onto the decking which might have 
become damaged or dislodged from the flooding. Anyone falling through such decking would have no 
ready means to escape. Consequently, it is not considered reasonably practicable to cover a channel of 
this type and size. Further a cover would only be across the screening channel itself and not the inlet. 

Company no. 09076541, C/O RES White Limited, Beaufort Court, Egg Farm Lane, Kings Langley, WD4 8LR 

Yorkshire Hydropower Limited 

 
 
 
 
 Yorkshire Hydropower Limited 

3.4 

3.5 

3.6 

3.7 

3.8 

3.9 

3.10 

We are reducing the attraction of this route at the upstream  end by extending the access along the 
screen  walkway  to  include  access  over  the  end  of  the  screenings  channel.  This  would  reduce  the 
attraction to climb through/over to see what is beyond. This will be achieved by relocating the existing 
end handrail and fitting additional mesh decking. 

We have also considered the feasibility of covering the top of the screening channel, between the fish 
pass bridge and the outlet bridge. The channel is some 750mm wide and would suit open mesh decking. 
Such decking however would not remove the risk of falling, just transfer it to the fish pass on one side 
or the outlet channel on the other. Covering the screening channel whilst not removing the risk could 
encourage people to walk along the decking. To prevent this we have considered hand railing on either 
side but again this would further suggest that this was a thoroughfare, which it is not. It is therefore not 
considered prudent to deck this channel as it is likely to increase the trespass risk and dangers associated 
with it.  

We have in turn also considered covering the fish pass, however the concern is that this could create 
hazards  which  do  not  currently  exist.  At  some  3.69m  wide  such  decking  would  require  substantial 
support steelwork to support the individual panels. The level at which such decking would be placed 
would have to vary in line with the varying height of the side walls and differences in level from one side 
to the other.  

The overall profile would be for the level of the decking to have to fall as the side walls to the fish pass 
itself fall. The fish pass is frequently submerged during flood conditions, this would present a number 
of hazards not least that of potentially pulling a person caught in the water beneath the covers. In such 
a situation any lifejacket or other item that they make take with them (such as an inflatable) would most 
likely trap a person resulting in drowning. Without covers such a person, whether a canoeist, swimmer 
or  person  simply  having  fallen  into  the  water,  would  be  flushed  out  downstream  with  a  chance  of 
subsequent rescue.  

In addition, Environment Agency guidance on fish pass design also discourages covers to fish passes as 
these can cause fish to be hesitant about using them.  

Presently access into this area is restricted by a locked access gate and as described in our response to 
paragraph 4, plans are in development to install a security fence to the left hand side to prevent access 
into the Facility from the weir and sluice gates. 

In  relation  to  any  cover  across  a  potentially  fast  flowing  channel,  debris  would  be  pulled  under  the 
covers and then pushed upwards exerting a force against the underside of the covers. Large debris such 
as sections of trees etc. would produce significant upwards forces with potential to damage the decking 
and support steelwork. Such decking would require inspection post flood to ensure that  it remained 
intact and safe. This inspection and potential repair work would, in itself, present risks to maintenance 
teams  that  do  not  currently  exist.    Finally,  it  is  again  of  general  concern  that  such  covers  would 
encourage persons to walk on them creating the perception that this area was safe.  

3.11 

It  is  therefore  considered  that  preventing  access  onto  the  walls  is  a  preferable  method  rather  than 
allowing such person onto the walls and then trying to keep them safe. 

3.12  With reference to access along the capping beam which encloses the outlet channel, we have had to 
balance the need for any structures to be robust so as to resist flood impact and also to be reasonably 
accessible  for  maintenance  (for  example  through  the  use  of  hand  tools).  We  will  be  installing  a 
galvanised steel fan, bolted to the capping beam and spanning out over the outlet channel.  

Company no. 09076541, C/O RES White Limited, Beaufort Court, Egg Farm Lane, Kings Langley, WD4 8LR 

Yorkshire Hydropower Limited 

 
 
 
 
 Yorkshire Hydropower Limited 

3.13  We are also going to install galvanised steel fans across the wall that boarders the fish pass. This will 
prevent access to that ledge from each end and  also a possible access point adjacent to the turbine 
house.  

3.14 

3.15 

3.16 

4. 

4.1 

4.2 

4.3 

4.4 

4.5 

5. 

5.1 

Another area which we have further reviewed is the very downstream end of the outlet, to block this 
route we will install a further fan located just upstream of the escape ladder, combined with a small 
panel of fencing. 

Another area which has had interest from trespassers is the high level bridge across the intake penstock 
which provides operational access to the penstock actuator. Access to the bridge is via a vertical ladder. 
We will be installing a hinged, and lockable plate, fitted to the ladder to prevent it being climbed by 
unauthorised persons. 

In overview we have tried to look at access to all areas within the Facility, particularly focussing on where 
there  are  drops  to  channels.  Having  carefully  considered  the  feasibility  of  covering  them,  we  have 
determined that to do so will introduce other risks that are more likely to result in an incident with the 
consequence of serious injury. Covering the channels may guard against one risk, but in practice will 
create a greater exposure to danger. The series of fans and gates present a more effective and ultimately 
safer measure of trying to block off these routes to trespassers. 

Response to Paragraph (4)  

The route used by Elliot to access the Facility was to walk across the weir from the bank opposite, climb 
over the sluice gate structure and over a timber fence. The sluice gates (which are a listed structure) 
and the weir substantially predate the construction of the Facility.  

The sluice gates and weir are not on land which is owned or controlled by YHL. Since the tragic incident 
YHL has sought to engage with the relevant parties to consider whether it is feasible to construct an 
additional barrier on or around these structures where they interface with the Facility.  YHL does not 
have the authority to take action unilaterally in relation to any such works. 

YHL has been part of a working group with WMDC and CRT since before the inquest. YHL commissioned 
a detailed options report which formed the basis of the final design, agreed by the group, for a barrier 
at this location. The details of that design have been submitted by WMDC to the local planning authority. 

YHL  are  supporting  WMDC  in  the  procurement  process  for  the  steel  works  while  the  planning 
application is being reviewed. 

As WMDC take the lead to see construction through to completion, YHL will continue to input on design 
and procurement where necessary, as well as facilitating the actual construction. 

Response to Paragraph (5)  

YHL has taken a number of actions to review and implement measures to deter unauthorised access to 
the Facility and, should access be gained, to try and minimise the risks that are present. The dynamic 
environment,  the  impact  of  flood  water  and  debris  as  well  as  the  requirement  to  facilitate  safe 
operational access makes this site very challenging. YHL has  shown that it is committed to continual 
improvement. In summary since Elliot's tragic death, the key measures that YHL has implemented are: 

(a) 

Additional  fence returns and mesh infills to deter  climbing/access from the land side of the 
Facility 

(b) 

Additional warning signs  

Company no. 09076541, C/O RES White Limited, Beaufort Court, Egg Farm Lane, Kings Langley, WD4 8LR 

Yorkshire Hydropower Limited 

 
 
 
 Yorkshire Hydropower Limited

(c) 

(d) 

(e) 

(f) 

(g) 

(h) 

Enhanced CCTV system (with greatly improved coverage and resolution), actively monitored at 
all times. 

Improved PA system to enable loud warnings to be issued remotely on detection of trespassers. 

Various measures to block off routes within the Facility, through the use of barriers and secure 
gates. 

Covering of some channels where practicable to do so. 

Ongoing liaison with the local emergency services. 

Daily manned security presence during summer months from 10am to 8pm.  

5.2 

5.3 

It remains the case that both youths and also adults are accessing the Facility or attempting to do so 
with little regard for their own safety. We are addressing areas of vulnerability as we become aware of 
them.  

Whilst traversing across the weir in itself presents significant risk to the individual, we are aware that 
this remains a key vulnerability in terms of the security of the Facility. It is anticipated that with the 
progress now being made with the riverside fencing this will soon be addressed. In the interim, we hope 
that the ongoing manned security presence and remote monitoring will deter further trespass. 

6. 

Summary  

6.1 

6.2 

6.3 

6.4 

The Facility was designed to be a safe working environment within a secure outer perimeter. To that 
end a complete security fence was installed to keep trespassers out of the Facility, and guard rails and 
approved access routes were provided to keep authorised persons within the Facility safe.  

Following  the  death  of  Elliot  Burton  in  July  2019  investigations  have  demonstrated  that  despite 
significant  and constantly developing measures to prevent  unauthorised access some individuals are 
still determined to access the Facility and are prepared to take on significant risks to their own safety in 
order to do so.  

This presents numerous challenges due to the location of the Facility and the time it takes to respond 
to  trespass  entries,  time  which  the  entrants  know  they  have  before  they  are  likely  to  be  physically 
challenged by police or security staff. The site is complex and presents many potential hazards to those 
prepared  to  actively  bypass  passive  safety  devices.  However,  normal  preventative  measures  are 
complicated by the Facility’s location within a flood plain and an active flood zone. This necessitates 
specific measures to ensure the Facility’s resilience to such flooding and the safety of the maintenance 
contractors who are responsible for clearing up and repair the Facility following these natural events.  

It  is  not  possible  to  remove  all  potential  risks  from  a  site  such  as  this  and  there  remains  a  balance 
between ensuring the safety of those who make a  deliberate attempt  to gain  unauthorised  entry to 
private  property  and  those  who  have  to  legitimately  operate  and  maintain  the  same  Facility.  The 
measures detailed and discussed in this response seek to manage that balance to ensure that the Facility 
remains safe and operational yet minimise the risks to all people, even those who choose to trespass. 

Director for and behalf of Yorkshire Hydropower Limited 

Company no. 09076541, C/O RES White Limited, Beaufort Court, Egg Farm Lane, Kings Langley, WD4 8LR 

Yorkshire Hydropower Limited

Canal &
River Trust

Making life better by water

Coroner's Office and Court
71 Northgate

Wakefield

WF1 3BS

29" June 2021

Dear Sir,

Inquest touching the death of Elliot Peter Burton
Regulation 28 Report to Prevent Future Death

| am responding on behalf of the Canal & River Trust (“the Trust”) to your Regulation 28 Report
dated 30" April 2021 (received by the Trust on 11" May 2021), in light of the tragic and untimely
death of Elliot Peter Burton.

| confirm that | am duly authorised to respond to your report on behalf of the Trust.

You have set out that you believe the Trust has the power to take action to prevent future deaths.
The Trust’s connection with your investigation is that the Trust is part-owner of Kirkthorpe weir.
The Trust owns the western half (the Eastmoor estate side) of the weir. The weir is essential in
maintaining water levels (known as “navigation levels”) to allow boats to use the Aire & Calder
Navigation which is operated by the Trust.

The hydropower scheme operated by Yorkshire Hydropower Limited (YHL) is on land owned by
Wakefield Metropolitan District Council (WMDC) and WMDC own the Eastern half of the weir
adjacent to the hydroscheme itself. Both banks adjacent to the weir are owned by WMDC.

The Trust has and continues to proactively engage with the other parties involved (YHL and
WMDC) in relation to shared risks at Kirkthorpe Weir and the implementation of control measures
as appropriate.

There have been a number of meetings between the Trust (myself attending) and representatives
of WMDC and YHL. We have discussed the risks and potential mitigations, and the outcome of
those discussions is a proposal to install a fence at the interface between the hydroplant and the
sluice gates. This would be on land not owned or managed by the Trust, though the Trust is a

Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB
W: www.canalrivertrust.org.uk

statutory consultee for any planning applications which may affect the weir and navigation. We
will provide our statutory responses to any planning applications as a matter of priority.

We are aware that WMDC are considering the installation of a fence or other deterrent along the
western bank which will not prevent access to the weir but will deter it. It is also hoped that the
installation of interpretation panels with Water Safety Messaging (which the Trust has developed)
will also have a deterrent effect.

We note that your letter has been sent to media representatives with a view to conveying the
nature of the risks to families living on the nearby Eastmoor Estate. Following Elliot's tragic death,
the Trust has rolled out a number of educational and outreach activities as part of its 2020-2021
programme and this work continues, including:

e A Schools Water Safety Awareness Communication produced by the Trust's national
Education team. This is a series of on-line learning bundles aimed at children (5-11 years) for
teachers, uniformed groups and parents to use at home while schools were closed.

e Awater safety video aimed at children aged 5 — 11 years which focuses on the Trust's ‘Stay
Away From the Edge’ message and explains what to do in an emergency.

e All primary schools across Wakefield and surrounding area have received multiple emails
as part of both Drowning Prevention Week in (June 2020 and June 2021) and our Winter
Water Safety Campaign (Nov 2019 & Nov 2020) containing links to our water safety
resources. In addition, all primary schools in the area were offered our free digital Water
Safety session (Jan 2021)

Since July 2019, the Yorkshire & North East region has delivered water safety sessions that
reached 7942 children up to the age of 11 across the Region.

| believe that this addresses all of your concerns.

Yours faithfully,

gees

Director Yorkshire & North East
Canal & River Trust

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