Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0336, written 22 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Oct 2022 |
|---|---|
| Reference | 2022-0336 |
| Deceased | Ruwaida Adan |
| Coroner | Leanne Woods |
| Coroner area | East London |
| 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.
MR GRAEME IRVINE SENIOR CORONER EAST LONDON East London, Queens Road Walthamstow, E17 8QP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: 14892552 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Capital Karts Trading Ltd, 15 Cabot Square, Canary Wharf, London, E14 4QS 1 CORONER I am Leanne Woods assistant coroner, for the coroner area of East London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 19 August 2021 I commenced an investigation into the death of Ruwaida Abdi Adan age 15 years. The investigation concluded at the end of the inquest on 13 October 2022. The jury found the cause of death was: 1a Hypoxic Brain Injury, 1b Asphyxiation The jury's conclusion was a narrative conclusion: "No safety check ensured that Ruwaida removed her headscarf before getting into her go-cart. No daily mechanics' check was carried out on August 6, 2021. In Ruwaida's cart the plastic drive belt guard to the rear axel was absent and the rear seat shield was damaged. Both should cover exposed moving parts. Ruwaida's scarf became entangled in the moving parts resulting in her asphyxiation and her death on August 10, 2021." 1 4 CIRCUMSTANCES OF THE DEATH On 6 August 2021 Ruwaida, age 15, went karting at Capital Karts, Barking as part of a summer programme for young people arranged by Newham Council. On that day she was wearing a religious headscarf. The evidence at the inquest was that Ruwaida should have been instructed to remove that headscarf and checks should have been done, at various stages, to ensure she removed it. However, she entered the pit lane wearing the headscarf under the karting helmet and started to race whilst wearing her headscarf. This was not identified by staff at Capital Karts before she began karting. The jury made findings in relation to the condition of the kart. The evidence at the inquest was that a kart in that condition should not have been driven. Ruwaida's headscarf became entangled in the kart's moving parts. The headscarf was pulled tight around her neck leading to asphyxiation and ultimately her sad death. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Whilst I received evidence that the system at Capital Karts has changed so that a person wearing a headscarf is now required to remove the item in reception and that must be witnessed, I continue to have a concern that there is a risk of future deaths. 1. I am concerned about the current system's apparent reliance on checks at the reception area, particularly when it comes to long hair, which obviously cannot be removed and so may be untucked from a suit or come out of a suit before karting commences. 2. A current race director, who was a race director on 6 August 2021, stated it was a regular occurrence that track marshals did not spot loose clothing or hair outside a race suit. He said that when he raised this with marshals he would notice an improvement but then see a lapse again. 3. CCTV of the pit lane from 6 August 2021 showed a number of people with long hair hanging loose outside the race suits. The duty manager said that this hair and Ruwaida's headscarf were missed but had no idea why this happened. 4. Capital Karts conduced spot checks and used 'mystery shoppers' as part of the supervision of staff. This system has been used since 2013, i.e. was in operation at the time of Ruwaida's death. 5. There was no evidence about changes to training and/ or monitoring of tracks marshals (asopposed to staff working in reception). 6. My concern is increased by the evidence of Capital Karts' managing director during the inquest. At various points in his evidence he said that, on 6 August 2021, his staff "did their job", followed their training and did the checks they were required to do prior to racing (or words to that effect). As a result of the evidence from the managing director, I have a concern about the nature of Capital Karts' understanding of, and commitment to, addressing the concerns identified in the inquest about the adequacy of checks on clothing performed by marshalls 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 2 [AND/OR your organisation] 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 19 December 2022. 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 Ruwaida Abdi Adan (via Leigh Day Solicitors), London Borough of Barking & Dagenham, Health & Safety Executive, CDOP and to the local director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 [DATE] 22 October 2022 [SIGNED BY CORONER] 3
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.
FAO HM Assistant Coroner Leanne Woods
East London Coroners Court
Queens Road
Walthamstow E17 8QP
16th December 2022
Dear Madam,
Inquest touching the death of Ruwaida Abdi Adam
Response to Regulation 28 Report to Prevent Future Deaths
I confirm receipt of your Regulation 28 Prevention of Future Death Report dated 22 October
2022 and this letter has been prepared in response to the matters of concern which you
have raised. I shall attempt to deal with all of the matters raised in turn.
As you indicate within your report, Capital Karts had already taken steps prior to the Inquest
to seek to ensure that there was no possibility of the repetition of the specific events leading
to Ruwaida’s death. The evidence at the Inquest was naturally directed principally at the
issue of head scarfs and I am grateful to have the opportunity to be able to confirm the wider
systems which have been implemented to deal with both loose clothing (including head
scarfs) and long hair, which have always been recognised as presenting a risk of injury if
they are not removed or secured (as applicable) prior to anyone participating in karting
events.
The process of providing appropriate safety information now begins at the booking stage. All
bookings are made in advance and the response provided by the company with all booking
confirmations now includes safety information including a clear warning that head scarves
will have to be removed before a person will be able to participate in any karting activity.
This warning is repeated in a further communication now sent to the customer prior to their
arrival at the venue.
This information is reiterated when customers arrive at the venue’s reception. Customers
are expressly told that long hair will have to be tied up and head scarfs and other loose
clothing will have to be removed. The specific change made since Ruwaida’s accident is
that reception staff will, in addition to issuing this instruction, have to directly observe that
there has been compliance before any further admittance to the venue is permitted. This is
undertaken with appropriate sensitivity so that, for example, a private place will be provided
so as to enable a female member of staff to witness a customer’s removal of their head
scarf. If, for any reason, a customer is not able to comply with these requirements, they will
not be permitted to participate in any karting activities and a full refund will be provided.
A written declaration that covers, amongst other things, that these instructions have been
understood and will be complied with must also be completed and signed by all customers
over the age of 18 years; and by parents/responsible adults for those participants under the
age of 18 years.
The pre-race briefing is now conducted by way of a pre-recorded video presentation, which
includes specific warnings in relation to long hair and loose clothing. That safety information
is further confirmed by notice boards providing the same warnings which are located in the
briefing room and the pit lane area.
An additional safety check is now also specifically carried out by the Race Director within the
briefing area so as to ensure that no customer has any loose clothing or long hair which has
not already been removed or secured as applicable. For racers with long hair, this means
that their hair, which will have been tied in reception, must be secured within their fastened
racing suit. Customers will not be able to leave the briefing area and move to the pit area
unless this individual check has been satisfactorily completed. It is therefore no longer
possible for any customer to enter the pit area with any loose clothing, including a head
scarf, or long hair which has not been secured within their racing suit.
The pit lane marshals continue with their pre-race safety checks, which includes helmet
checks and a further safety check for any prohibited items, including loose clothing and any
long hair outside of the racing suit at both the gate to the racing area and when customers
are then seated within their karts. The final warning against loose clothing and long hair is
provided by way of the safety decals on the steering wheel on the karts.
The kart racing itself continues to be supervised by marshals and by a Race Director, who
has access to high-definition cameras, so as to monitor drivers and identify any safety issues
which may develop during the race.
The current systems are therefore not reliant on checks within the reception area. A series
of individual checks are made beginning with the reception area, but then continuing with
separate checks within the briefing area; and then the pit area so that it can be ensured that
long hair has been secured within the racing suit and has not become untucked, and further
that any loose clothing has been removed.
Marshals and other staff associated with the racing operations are provided with very
comprehensive training manuals and training sessions so as to ensure that they are fully
aware of all of their safety duties and responsibilities, including their obligation to ensure that
the rules as to loose clothing and loose hair are enforced. Their understanding of those
rules and their ability to implement them in practice are also assessed by an experienced
Race Director before they are certified as competent to work. Race Directors are also
tasked with overall supervision of all racing activities, which includes a requirement to
monitor the work undertaken by marshals. Any concerns as to the performance of marshals
identified by the Race Directors are promptly addressed.
The company does continue to conduct spot checks and use ‘mystery shoppers’ so as to
ensure that its expectations as to the performance of its staff are being met in practice.
These had not disclosed any issues in relation to the proper undertaking of safety checks by
staff prior to Ruwaida’s accident but these checks continue so as to ensure that safety
standards are consistently and fully achieved. The evidence in relation to 6 August 2021
did confirm that two customers with long hair had been identified and instructed to secure
their hair within their race suits before they were permitted to begin the karting activity,
although, as you note in your report, the track marshals did not identify the head scarf worn
by Ruwaida under her helmet as part of their pre-race checks. As set out above, the
systems now in place will ensure that such clothing would have been witnessed being
removed before a customer would even be admitted into the venue.
In respect of my own evidence to the Inquest, I had hoped to convey that the safety of all
customers has always been both my and the company’s primary concern, particularly given
the inherent risks associated with karting as an activity. I also hope that this was
demonstrated by the systems which the company had put in place to ensure that customers
were aware of the risks associated with loose clothing and loose hair; the training which was
provided to staff; and the checks which were made of each participant before racing
commenced. However, notwithstanding that we had believed that our systems were in line
with industry standards, we promptly instituted a review following this tragic accident
because we were determined to ensure that there could never be a repetition of it. That
process led to our implementation of the additional and enhanced safety measures which I
have set out above.
I sincerely hope that these actions which I have outlined and confirmed in this response
addresses the matters which you have raised by way of your report. Everyone associated
with Capital Karts deeply regrets the accident and the loss of Ruwaida and we are
determined and fully committed to ensuring that a similar accident could never happen
again.
Should you require any further information relating to my response, please do not hesitate to
contact me.
Yours sincerely
Managing Director
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