Prevention of Future Deaths reports · 2022
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 report | 7 Apr 2022 |
|---|---|
| Reference | 2022-0109 |
| Deceased | Laura Smallwood |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
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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