Prevention of Future Deaths reports · 2022

Laura Smallwood

Regulation 28 report to prevent future deaths, reference 2022-0109, written 7 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report7 Apr 2022
Reference2022-0109
DeceasedLaura Smallwood
CoronerAndrew Cox
Coroner areaCornwall and the Isles of Scilly
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Information  Classification:  CONTROLLED 

REGULATION  28  REPORT  TO PREVENT  FUTURE  DEATHS 

THIS  REPORT  15  BEING  SENT TO: 

1.  The Rt  Hon  Kit Malthouse  MP, Minister for  Crime &  Policing 

1 

CORONER 

I am  Andrew Cox,  HM  Senior Coroner for the coroner area  of Cornwall  and  the  Isles  of 
Scilly. 

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  7.4.22,  I concluded an  inquest into the  death of Laura Amy Smallwood, a 34-year-old 
paediatric nurse,  who  died  in  University Hospital Plymouth on 4.5.19. 

The  medical cause  of death was  recorded as: 
1a)  Brainstem  infarction; 
1b)Bilateral  vertebral  artery  dissection 
1c) 
II) 

I recorded  a Conclusion of an Accidental death. 

4 

CIRCUMSTANCES  OF THE  DEATH 

May  Day is  celebrated  annually  in  Pad stow with  what  is  called the Obby Oss  festival. An 
Oss is  a hooped structure resembling  a hobby horse that  weighs  about 50lbs  and  is 
processed through the streets  over the course of the day. There  are  two  separate 
'Osses.' The  day is extremely  popular and  can attract up  to 20,000  visitors to the town. 

On  1 May 2019,  Laura  was  unintentionally  struck to the  back of her neck  by an  Oss 
when  the carrier lost his  balance and  fell over. She  deteriorated acutely at the scene  and 
suffered a respiratory  arrest.  She  was  taken by air ambulance to hospital but died from 
her injuries. 

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.  -

Until  recently,  there  had  been a lack of involvement by the Oss  committees with the 
Local  Safety Advisory Group (LSAG.) This  had  compromised  planning and  risk 
management  for the event.  That  situation has  improved significantly with the 
appointment of an  external  liaison officer by the Oss committees. 

Those  who  attend  May  Day from the Oss organisations, however,  represent  only a small 
fraction of the total number of attendees. At inquest, I heard  that there  is  still no  one 
willing  to act as  an  'Event Organiser'  for the May  Day event as  a whole  despite repeated 
requests from the police for this to happen. As a consequence,  there  is  no  single point of 
contact for the police or others  and  no  one who  is engaged  with the  LSAG  to look at 
public safety. 

I heard  in  evidence that the  current  legislative framework does not provide the police or 

1 

 Information  Classification:  CONTROLLED 

any other agency with  powers  in  law to insist on the  appointment of an Event Organiser. 
Further,  neither  the  police nor any other agency have powers  in  law to grant or refuse 
permission to hold an  event where  there  are  significant concerns around  public safety.  I 
enclose statements from: 
Inspector 
PS 

; 

 with  counsel's advice. 

-
-
-

If these submissions are  correct, this gap in  legislative oversight is  relevant  not simply 
for the May Day festival in Padstow but for events  nationally. What  is  the expectation of 
government,  in  terms  of the management  of public safety, where there  is  no  Event 
Organiser to engage with  a LSAG and  other agencies  like the police? 

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. The  matters  I bring to your attention are: 

- Whether  there  is  adequate legislative authority currently  to ensure  public safety 
at gatherings where  there  is  no  Event Organiser to liaise with an  LSAG  or other 
external  agencies? 

- Whether  additional powers  need  to be given to the  police or others to grant or 
refuse permission for a particular event to take place in  the absence of the 
appointment of an  Event Organiser  with  meaningful engagement  with an  LSAG 
so that public safety considerations are properly addressed? 

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 June.  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 of Laura  Smallwood, the representative  of the Blue and  Red  Oss 
committees and  Devon & Cornwall  police. 

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 

[DATE] 

7.4.22 
· 
~ 

[SIGNED  BY CORONER] 

2

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Home Office (PDF)
Mr Andrew J. Cox 
HM Senior Coroner 
Cornwall & the Isles of Scilly 

By email only: 

Tom Pursglove MP 
Minister of State 
2 Marsham Street 
London SW1P 4DF 

Our ref: MIN/0291376/22 
Your ref: AJC/LJB/310320 

14 July 2022 

Dear Mr Cox, 

Re: Regulation 28 Prevention of Future Deaths letter Re: Laura Amy 
Smallwood 

I am grateful to you for bringing to my attention the circumstances surrounding 
the death of Laura Smallwood. I was saddened to hear how what should have 
been an enjoyable day turned out so tragically. I would ask that you please 
convey my condolences to Laura’s family and friends. 

When you wrote to Minister Kit Malthouse on 7 April 2022 you raised two 
issues: 

- Whether there is adequate legislative authority currently to ensure 

safety at public gatherings where there is no Event Organiser to liaise 
with an LSAG or other external agencies; 

- Whether additional powers need to be given to the police or others to 
grant or refuse permission for a particular event to take place in the 
absence of the appointment of an Event Organiser with meaningful 
engagement with an LSAG so that public safety considerations are 
properly addressed. 

I appreciate you extending the deadline for me to respond thereby allowing 
me to consult colleagues across Government who have responsibility for 
national policy around public events and health and safety. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We want public events to be safe for those who take part or spectate, and for 
the vast majority of the time that is what we see.  That is often thanks to the 
people who are willing to take on responsibility for aspects of the organisation 
and liaise with the local authorities to draw on their expertise in keeping 
people safe.  I was pleased to read in your report that some element of that 
now happens with the Oss committee. 

As you indicate, however, the Safety Advisory Groups do not have a statutory 
basis.  This does mean the SAG has no limitations as to what events it 
considers, should it so desire. It can consider events regardless of venue -
public or private; free to attend or ticketed; traditional or novel events; regular 
or occasional; or voluntary or charitable. 

It does also mean that attendance or engagement with the Safety Advisory 
Groups is voluntary and there is no legal requirement to appoint an organiser 
or to engage with the local authority or law enforcement. The Cabinet Office’s 
Emergency Planning College (EPC) recognises this possibility and notes that 
it may be challenging. It is the Government’s view that where there is no 
organiser, or an event organiser declines to engage in safety processes, it 
should not prevent the Safety Advisory Group taking reasonable steps to 
review the safety arrangements of an event.  The EPC guidance, The UK 
Good Practice Guide to Working in Safety Advisory Groups, states: 

“It is important to consider why an organiser is unwilling or unable to engage. 
It will be important to demonstrate that a SAG is well intentioned and focused 
on working with organisers, by considering the safety aspects of their event. 
The SAG should not be considered as a threatening environment as the 
safety of all involved in an event should be mutually beneficial. The SAG 
should not make unreasonable or unfair demands on the organiser and the 
options highlighted in section 3.8 under ‘smarter working’ should be 
considered. These include technological solutions such as 
video/teleconferencing. The SAG should also guard against placing 
disproportionate demands on organisers of what are obviously very low-risk 
events. Wherever possible SAGs should still seek to assess the safety 
arrangements of an event, despite such a lack of participation by an 
organiser. It should also then address any issues raised by the most 
appropriate means. It will be particularly important to ensure that accurate 
and appropriate records of representations and correspondence are 
maintained in these situations. In any case, the SAG chair should coordinate 
its members’ desires and attempts to communicate with the organiser, 
ensuring that attempts are recorded and properly documented.”1 

Those who attend Safety Advisory Groups do have a range of powers that 
may be applicable.  For example, the local authority will have licensing powers 
and the Health and Safety at Work Act 1974 would apply where the planning, 
organising, or running of an event is a work activity.  In extremis, the police 

1 Emergency Planning College, The UK Good Practice Guide to Working In Safety Advisory Groups, 
Part 2 Supporting Appendices (The Emergency Planning College: 2019), 12 Microsoft Word - The 
UK GPG to WSAG Part 2 (epcresilience.com) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 could act to prevent a breach of the peace. The EPC’s guidance sets out the 
powers which may be relevant in more detail.2 

The Government believes there is great value to our national life in 
communities being able to celebrate their local traditions, bringing people 
together to take pride in their area, and strengthening community spirit. 

For that reason, we have taken the view that it is better to support and 
encourage sensible planning and preparation, rather than to mandate every 
element of it through legislation.  The latest public guidance from the Cabinet 
Office (Organising a voluntary event: a 'can do' guide - GOV.UK (www.gov.uk) )is 
intended to help people planning voluntary events, with advice on the steps 
that organisers should take. 

To amend the law in this area sadly would not necessarily prevent the – 
mercifully rare – occasions when something goes tragically wrong as it did in 
this case.  Consequently, the government believes that we should continue to 
encourage those wishing to organise events to engage sensibly with local 
experts to keep people safe. 

Yours Sincerely, 

Tom Pursglove MP 
Minister of State 

2 Emergency Planning College, The UK Good Practice Guide to Working In Safety Advisory Groups, 
Part 2 Supporting Appendices, 4-11

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