Prevention of Future Deaths reports · 2023

Michael Holmes

Regulation 28 report to prevent future deaths, reference 2023-0023, written 20 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Jan 2023
Reference2023-0023
DeceasedMichael Holmes
CoronerKevin McLoughlin
Coroner areaWest Yorkshire (Eastern)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

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: 

1.  The Rt Hon Dr Therese Coffey MP, Secretary of State for Environment 

Food and Rural Affairs. 

2.  J A Mitchell & Sons   
3.  Wakefield Council – 
4.  Health and Safety Executive – 

1 

CORONER 

 Principal Inspector 

I am Kevin McLoughlin, Senior Coroner for the Coroner area of West Yorkshire (East) 

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 1 October 2020 I commenced an investigation into the death of Michael John 
Holmes, aged 57. The investigation concluded at the end of the Inquest on 18 January 
2023. The conclusion of the Inquest was Accidental Death. 

4 

CIRCUMSTANCES OF THE DEATH 

On Tuesday 29 September 2020, Michael John Holmes and his wife were walking dogs 
belonging to other family members on leads in a field at Hollinghurst Farm, Netherton, 
Wakefield. Cattle in the field approached them, knocked them down and trampled them, 
causing serious injuries. Emergency treatment was provided by a doctor who arrived by 
helicopter. Mr Holmes could not be revived and was pronounced dead at 12:56 that day 
at the scene of the incident. 

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: 

1. Considerations regarding the field where the fatality occurred. 

1.1. In an incident on 29 September 2020 Mr Holmes died after being trampled by cattle.  
His wife sustained major spinal and other injuries.  It was a catastrophe for their 
family. The couple were walking on a public footpath which ran through the middle 
of a large field. It occurred as they were on a lunchtime walk at a time when they 
were working from home due to the Covid pandemic.  

1.2. Statistics from the Health & Safety Executive (‘HSE’) indicate that on average 6 

people have died each year from injuries sustained in cattle trampling incidents.  11 
people died in 2020, one of whom was Mr Holmes.  Such incidents are avoidable if 

1 

 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 walkers and cattle are separated.  In my judgment, this unacceptable situation 
necessitates a review of the arrangements in which walkers are brought into contact 
with cows and their calves, by virtue of rights of way. 

1.3. The field in which the incident occurred (the ‘incident field’) had been used to graze 
cattle for over 50 years.  The public footpath had existed since the National Parks & 
Access to the Countryside Act 1949 recorded its existence.  The logic for the precise 
path through the incident field has been lost in the mists of time. 

1.4. Following the fatal incident, the farmer made a formal application dated 12 January 
2021, to divert the public footpath to the edge of the incident field and erect a 
suitable fence, so as to create a safe corridor which separates walkers from the 
cattle (the ‘application’).  All the witnesses who gave evidence at the inquest 
endorsed the wisdom of the application.  One described it as “essential.” 

1.5. As objections have been lodged to the application, the matter must be resolved by 
way of a public enquiry.  The Secretary of State is asked to ensure the decision 
maker in such a process is aware of the unanimous views expressed in the course 
of the inquest. The application may well eliminate altogether the risk identified in the 
incident field. 

2.  The general position in relation to dogs on Rights of Way 

2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most 

common factors in trampling incidents are cows with calves and walkers with dogs. 
Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence 
about four previous incidents in the incident field, three of which involved walkers 
accompanied by dogs.  There appears to be a strong correlation between trampling 
incidents and walkers with dogs. 

2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, 

particularly when the calves are young. 

2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual 
accompaniment’ and are thus entitled to be brought onto a Right of Way.  This 
proposition lacks clarity. There is also uncertainty as to whether dogs are required to 
be on a lead when on a public footpath. 

2.4. Consideration should be given in the HSE Information Sheet to a clarification of the 
legal position of dogs brought onto rights of way where it is foreseeable they will 
interact with cows and their young calves. 

3.  The power to restrict dogs on public footpaths, at certain times. 

3.1. It is difficult to predict whether a particular cow will react aggressively to the  

presence of a dog in a field. It was suggested during the inquest, the risk of such a 
reaction is highest in the months after the birth of a calf.  

3.2. To neutralise this risk, consideration should be given to empowering Local Authority   
Footpath officers (on an application made by a farmer in relation to an identified 
field), to prohibit dogs being taken onto the field for a specified period. In short, a 
temporary prohibition order.  The rationale for a temporary expedient of this nature 
is the imperative to protect the safety of the public, when set against the relatively 
brief interference with any right a walker may have to be accompanied by a dog. 

3.3. An alternative approach would be to authorise landowners to post notices at the  
       entrance to particular fields, alerting walkers to the presence of cows with young   
       calves and advising them not to bring dogs into the field (whether on a lead or not)     
       between specified dates.  The objective of preventing harm may not, however, be      
       achieved if walkers ignore the advice or the suggested signs are vandalised. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 3.4   It is acknowledged that statutory change would be required to create powers of this  
        nature.  The Secretary of State will doubtless reflect upon the balance to be struck   
        between the imperative of protecting the safety of the public and the relatively brief  
        interference this would impose on the right of walkers to bring their dog into any   
        field affected. It should also be borne in mind that the people whose safety is   
        currently jeopardised under existing arrangements are the dog walkers themselves. 

4. The role of public bodies. 

4.1. The current potential for a hazard to be created by walkers on public footpaths  
       moving in proximity to a farmer’s grazing cattle, requires management of these      
       competing interests.  It was contended at the inquest that the farmer is subject to a  
       statutory duty to carry out a risk assessment in accordance with the Management of  
       Health & Safety at Work Regulations 1999. It was contended that a landowner must   
       conduct his business around the existing public footpath, irrespective of which came  
       into existence first. Whilst not disputing the legal duty imposed on a farmer in these  
       circumstances, the potential mischief left unguarded in that analysis, is that Small &  
       Medium Enterprises (SME’s) such as small family farms may lack the expertise to  
       recognise the problem, carry out an effective risk assessment in relation to cattle  
       trampling risks and devise reasonably practicable control measures. 

4.2.  To avoid the harm envisaged by further deaths in comparable circumstances,  
        the HSE and Local Authorities should explore ways to apply their expertise in   
        collaboration with landowners (of the type involved in this inquest), whether on a   
        paid or voluntary basis. The maintenance of safe public rights of way could be said   
        to require oversight and management by public bodies as well as the landowners  
        concerned 

4.3   One example of pragmatic help to eliminate cattle trampling risks would be for the    
        HSE to draw attention to the process available under section 119 of the Highways   
        Act 1980 to apply for a public footpath to be re-routed, so as to separate cows with   
        calves and walkers.  Consideration could be given to highlighting this option in a    
        future edition of the HSE Information Sheet. 

4.4  This report will be sent to special interest groups thought to have an interest in this  

issue, in the hope of enlisting their assistance in educating all who use the 
countryside in relation to the risk and the ways in which it could be eliminated. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and 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 31 March 2023. 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: 

 via CFG Law Solicitors 

I have also sent it to: 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Ramblers’ Association 
National Farmers Union 
Country Land Owners Association 
The Access and Rights of Byways and Bridleways Trust    
Open Spaces Society  
Rights of Way Review Committee  

– ITV Reporter 

 – BBC Reporter 

who may find it useful or of interest. 

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 

Kevin McLoughlin 
Senior Coroner 
West Yorkshire (East) 
20th January 2023                        

4

Responses

3 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.

Response from Defra (PDF)
The Rt Hon Thérèse Coffey MP 
Secretary of State Environment, Food & Rural Affairs 
Seacole Building 
2 Marsham Street 
London 
SW1P 4DF 

25 May 2023 

Kevin McLoughlin 
Senior Coroner 
Coroner’s Office and Court 
71 Northgate 
Wakefield WF1 3BS 

Dear Kevin,    

Thank you for your letter of 20 January with regard to the inquest into the death of Mi-
chael John Holmes. Firstly, may I say I am very sorry to hear of this tragic incident and 
my deepest sympathies go to Mr Holmes’s family. I would also like to apologise for the 
time take to respond. 

While many thousands of people enjoy the countryside and use the extensive network of 
footpaths, bridleways, and public access land every day, activities such as walking 
through or near cattle can be hazardous. Such incidents across the public rights of way 
network are rare however we do understand the concerns about ongoing public safety.  

Defra is responsible for rights of way policy and this response sets out Defra’s response 
to the points you have addressed to this department. I note that you have also copied 
your report to the Health and Safety Executive who have responded to you separately in 
light of their responsibilities for providing guidance to farmers, landowners and other live-
stock keepers about the assessment of risks posed by livestock being kept in a field with 
a public right of way. 

MATTERS OF CONCERN 

Considerations regarding the field where the fatality occurred  

We want people to be able to enjoy the countryside, but it is vital that people and animals 
are kept safe and it is important that there is information available to members of the pub-
lic about the risks posed by livestock in a field to which the public has a right of access 
and that landowners are aware of their responsibilities. 

The Highways Act 1980 gives powers for changes to be made to the public rights of way 
network including diversions where it is in the public interest. We are aware of the appli-
cation made to the local authority under Section 119 of the Act to have the public right of 
way in question diverted to mitigate the risk of such incidents in future.  

As you pointed out in your report, objections to the diversion have been received there-
fore an application has been made to the Planning Inspectorate which is currently pro-
cessing the application and will consider carefully any representations and objections re-
ceived in accordance with standard procedures before making a decision on behalf of the 
Secretary of State.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
         
 
 
 
 
 
 
 
 
 
 We are aware of calls for a change in legislation to enable temporary path diversion or-
ders however there are no plans to introduce such regulations at this time.  

However, we are committed to implementing a number of rights of way reforms which in-
clude giving landowners the statutory right to apply to a local authority for a public path 
order to permanently extinguish or divert a footpath or bridleway where it is in the public 
interest to do so. 

Section 59 of the Wildlife and Countryside Act 1981 bans bulls of seven recognised dairy 
breeds (i.e. Ayrshire, British Friesian, British Holstein, Dairy Shorthorn, Guernsey, Jersey 
and Kerry) that are over the age of ten months in all circumstances from being at large in 
fields crossed by public rights of way.  Bulls of all other breeds (again over the age of ten 
months and including continental dairy breeds) are also banned from such fields unless 
accompanied by cows or heifers.    

The general position in relation to dogs on Rights of Way and the power to restrict 
dogs on public footpaths, at certain times.  

There are clear messages for dog walkers on both their rights and responsibilities when 
out in the countryside.  Natural England’s recently updated Countryside Code sets out the 
responsibilities both for visitors to the countryside and land managers. It makes clear that 
visitors need to make sure dogs are kept under control around livestock and on open 
access land dogs must be put on a lead around livestock. Between 1 March and 31July a 
dog must be on a lead on open access land, regardless of livestock being present. This is 
a legal requirement. 

Land managers must warn visitors of any unseen hazards including livestock movements 
as well and not keeping animals that are known to be dangerous in places where there is 
public access. Local authorities already have powers through Public Spaces Protection 
Orders to place restrictions on dogs. 

The role of public bodies  

Defra and its statutory adviser, Natural England, are responsible for setting out the 
legislation framework and producing guidance for the management of the public rights of 
way network. Guidance is already available for the diverting of public rights of way in 
accordance with the Highways Act 1980 however as part of the rights of way reforms 
package we are taking forward we will look at how we can make this more accessible.  

Local authorities are responsible for the maintenance and management of public rights of 
way. 

Yours sincerely,
Response from Health and Safety Executive (PDF)
Health and Safety 
Executive 

Engagement & Policy Division 

Agriculture, Vulnerable Workers, 
Waste & Recycling Unit 
Hornbeam House 
Electra Way 
Crewe 
CW1 6GJ 

http://www.hse.gov.uk/ 

Kevin McLoughlin 
Senior Coroner for West Yorkshire (Eastern) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

28th  March 2023 

Dear Mr McLoughlin 

Inquest into the death of Michael John Holmes – Regulation 28 report. 

Thank  you  for  your  letter  dated  20th  January  2023  to 
  and  the  associated 
Regulation 28 report. I am the Health and Safety Executive’s (HSE) Inspector with the lead for 
operational  policy  in  relation  to  controlling  health  and  safety  risks  associated  with  cattle,  and 
have been asked to reply to you on the matters that you raise. 

We  note  your  report  was  sent  to  a  number  of  bodies  with  an  interest  in  this  issue.  This 
response will address matters that are within HSE’s areas of responsibility as a regulator, and 
highlight where matters are more appropriately addressed by other organisations. 

Introduction 

Incidents such as the one that  happened on 29th  September  2020  to Mr Holmes and his wife 
are not commonplace. There are many thousands of miles of public rights of way crossing the 
farmland  of  Great  Britain,  and  many  thousands  of  members  of  the  public  use  those  rights  of 
way each year without incident. 

HSE  are  Britain’s  national  regulator  for  workplace  health  and  safety,  this  includes  the  farm 
workplace.  The  principal  health  and  safety  legislation  enforced  by  HSE  is  the  Health  and 
Safety  at  Work  etc  Act 1974  (HSWA).  This  places  general  duties  on  employers  and the  self-
employed  to  conduct  their  undertakings  in  such  a  way  as  to  ensure,  so  far  as  is  reasonably 
practicable, that persons other than themselves or their employees are not exposed to risks to 
their health or safety. In the context of this incident it means there is a legal duty on all farmers 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to  manage  their  herd  so  the  animals  within  it  present  a  low  level  of  risk  to  members  of  the 
public who use fields with rights of way or other rights of public access. 

To  help  farmers  comply  with  their  legal  duties,  HSE  publication  AIS17  “Cattle  and  public 
access in England and Wales. Advice for farmers, landowners and other livestock keepers” is 
freely  available  to  download  from  our  website  at  http://www.hse.gov.uk/pubns/ais17ew.pdf. 
This  information  sheet  was  drawn  up  in  consultation  with  the  farming  industry  and  provides 
guidance  to  enable  those  with  duties  under  the  Health  and  Safety  at  Work  Act  to  meet  their 
legal obligations. 

While HSE has a role to play in assisting farmers to comply with their legal duties by provision 
of information and guidance, it also has a regulatory role through inspection and investigation 
to ensure that farms meet minimum legal standards in controlling risk. 

HSE works closely with members of Britain’s Farm Safety Partnerships (FSPs) to improve the 
health  and  safety  record  of  the  farming  industry.  Further  information  on  managing  risks  from 
cattle  is  available  via  members  of  Britain’s  FSPs.  The  information  provided  by  many  of  its 
member organisations extends to provision of  information  directly for the public,  as well as to 
the  actions  that  farmers  and  landowners  can  consider  where  a  risk  is  identified.  The 
information provided by these organisations compliments that published by Natural England in 
“The  Countryside  Code:  advice  for  countryside  visitors”  and  “The  Countryside  Code:  advice 
land  managers”,  both  available  at  https://www.gov.uk/government/publications/the-
for 
countryside-code. 

Dealing with the MATTERS OF CONCERN raised within your report: 

1.  Considerations regarding the field where the fatality occurred. 

In  relation  to  HSE’s  statistics  and  for  clarity,  over  the  last  5  years,  there  have  been,  on 
average,  6 deaths each year due to  workplace cattle related incidents.  These  deaths are not 
solely related to trampling incidents. The numbers relate to all workplace cattle related deaths 
to  farmers,  workers  and  members  of  the  public.  Each  year  HSE  publishes  a  report  on  the 
number  of  people  killed  as  a  result  of  farming  and  other  agriculture-related  activities.  The 
found  on  HSE’s  website  at 
latest 
https://www.hse.gov.uk/agriculture/resources/fatal.htm.  The 
that  animals 
(particularly  cattle)  are  one  of  the  largest  causes  of  farming  workplace  deaths.  Many  more 
people  are  very  seriously  injured.  This  is  why  it  is  so  important  that  farmers  follow  HSE  and 
industry guidance to reduce the risk to people from cattle. 

report  and  previous 

reports  show 

can  be 

reports 

On  the  issue  of  separation,  HSE  has  fully  considered  reasonable  control  measures  that  are 
flexible  and  proportionate  to  the  risk  presented  by  a  particular  herd  to  walkers  and  others. 
These are outlined in AIS17. 

The  measures  HSE  would  expect  farmers  to  have  considered  and,  where  possible 
implemented, include: 

  Preventing the keeping of dairy bulls in fields with public access at any time. 
  Where possible avoiding putting cattle, especially cattle that are calving or have calves 

at foot, in fields with public access. 

  Where there is  a need  to  keep cattle,  especially cattle that  are calving  or have calves 
at foot, in a field with public access, where reasonably practicable to do so the farmer 
should be keeping animals and people separated. This can be achieved by the use of 
fencing  (permanent  or  moveable  /  temporary  e.g.  electric  fencing).  Segregation  is 
particularly important at busy times or where fields with public access are heavily used. 

2 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Assessing  the  temperament  of  all  cattle  before  putting  them  into  a  field  with  public 

 

access. 
If cattle, especially cattle that are calving or have calves at foot, do need to be put into 
fields with public access, this period should be kept to a minimum. 

  Positioning feed and water troughs away from the public footpath and away from public 

entrances and exits to the field. 

  Having a reliable system to monitor all cattle in fields with public access at least daily. 
  Preventing  any  animal  that  is  suspected  of  showing,  or  has  shown  any  sign  of 
aggression  from  being  kept  in  fields  with  public  access.  This  should  extend  to 
consideration of culling any animal that shows signs of aggression. 

  Clearly  sign  posting  all  public  access  routes  across  the  farm.  Display  appropriate 
signage at all entrances to fields with cattle. Remove signage when the animals are no 
longer in the field. 

I  understand  from  your  report,  that  the  farmer  made  a  formal  application  to  divert  the  public 
footpath  to  the  edge  of  the  incident  field  and  erect  suitable  fencing  to  create  a  safe  corridor 
and  segregate  walkers from cattle.  The legislation  regarding rights of way  falls under  Defra’s 
responsibility and is not a matter for HSE, although we understand that the divert process can 
take time and does not offer a prompt solution. The issue of diversions, whether temporary or 
permanent,  and  of  the  provision  of  permissive  alternative  routes,  is  not  straightforward,  and 
may not always offer the best solution to manage the risks. 

In  recognition  of  this  HSE’s  AIS17  guidance  gives  pragmatic  short-term  options  that 
landowners and farmers can consider with regard to offering alternative routes to the footpaths 
crossing their land if their risk assessment shows this to be necessary. The guidance provides 
sufficient  information  to  allow  farmers  and  landowners  to  comply  with  their  legal  obligations 
under the HSWA. 

2.  The general position in relation to dogs on Rights of Way. 

Farmers have a duty to manage the risk created by placing cattle in fields with public rights of 
way.  HSE  does recognise  that the  presence of  a dog(s) and cows with  calves does increase 
the  risk  of  incidents.  However,  the  control  measures  already  outlined,  if  followed,  limit  the 
times  when  cattle  with  calves  are  in  fields  with  public  access,  and  if  there  is  no  alternative 
provide reasonable mitigation to control the risk to a low level. 

Your report states that dogs are “entitled to be brought onto a Right of Way”, but that there is 
“uncertainty  as  to  whether  dogs  are  required  to  be  on  a  lead  when  on  a  public  footpath”. 
These  are  not  matters  for  HSE,  the  legislation  regarding  rights  of  way  falls  under  Defra’s 
responsibility.  The  purpose  of  HSE’s  AIS17  is  to  outline  advice  for  farmers,  landowners  and 
other livestock keepers on how to comply with their legal responsibilities to reasonably control 
risk  to  people  using  public  rights  of  way.  As  mentioned  above,  other  publications  exist  to 
provide advice to members of the public on the control of dogs on public rights of way. 

Members  of  the  public  using  the  countryside  should  play  their  part  by  staying  on  the  right  of 
way while walking through the field and if with a dog(s) keeping it under control and on a lead. 
Additional  advice  is  outlined  in  the  free  online  publication  “The  Countryside  Code:  advice  for 
countryside visitors - GOV.UK (www.gov.uk)”. 

3.  The power to restrict dogs on public footpaths, at certain times. 

HSE  has  no role  in  empowering  LA footpath  officers  to  prohibit dogs from  fields  for specified 
periods so we can’t comment on this aspect of your report. 

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 In  relation  to  signage,  this  is  already  a  control  measure  that  is  available  to  farmers  and 
mentioned in our guidance.  We are aware that a number of organisations offer suitable signs 
to  their  farming  members.  Although  not  the  sole  means  of  achieving  a  reasonable  level  of 
safety when coupled with other measures they can still have a part to play in effective control 
of risk. 

The specific matter of posting notices at the entrance to particular fields specifically to  advise 
walkers  not  to  bring  dogs  into  a  field  containing  animals  between  certain  dates  is  outside  of 
HSE’s remit as a regulator, and is more appropriate for others to offer comment. 

4.  The role of public bodies. 

As explained  earlier  in this  letter, there is a legal duty on all farmers to manage their herd so 
the  animals  within  it  present  a  low  level  of  risk  to  members  of  the  public  who  use  fields  with 
rights of way or other rights of public access. 

Health  and  safety  law  applies  equally  to  large  and  small  companies.  Recognising  that  many 
duty  holders  don’t  have  in-house  expertise,  the  Management  of  Health  and  Safety  at  Work 
Regulations  1999  require  employers  and  partnerships  to  have  arrangements  to  access 
competent  advice  from  someone  to  help  them  understand  and  comply  with  their  obligations 
and  assist in  the  discharge  of  their  health  and  safety  duties.  This competent  advice is  widely 
available  from  agricultural  consultants,  farming  member  organisations  (e.g.  NFU)  or  via 
insurance companies. 

The  maintenance  and  management  of  public  rights  of  way  is  principally  governed  by  local 
authority  officers.  HSE  is  not  the  appropriate  authority  to  comment  on  the  Highways  Act 
provisions and the oversight matters you mention. 

Finally,  thank  you  for  your  suggestion  to  include  additional  information  in  AIS17  on  the 
mechanism to apply for a public footpath to be re-routed. We keep guidance, including AIS17, 
under  periodic  re-evaluation.  When  next  reviewed,  we  will  take  your  comments  into 
consideration. 

Yours sincerely 

HM Inspector of Health and Safety 
Agriculture Sector 

4
Response from Wakefield Council (PDF)
www.wokefield.gov.uk 

• 

Communities,  Environment and Climate Change 

Communities,  Environment and Climate Change 

Wakefield Council 
Wakefield  One 
Burton  Street 
WF1  2EB 

Tel:  0345 8 506 506 
Typetalk calls welcome 

13  March 2023 

HM Senior Coroner 
Mr Kevin Mcloughlin 
Wakefield Coroner's Court 
Coroners Office 
71  Northgate 
Wakefield 
WF1  3BS 

Dear Mr Mc Loughlin 

Re:  Inquest touching the death of Michael Holmes - Response to PFD report on behalf of 
Wakefield Council 
Further to the copy of the PFD report received on 20th  January 2023,  please treat this letter as 
Wakefield Council's formal response. 

The  PFD  report  was  addressed  for the  attention  of 
,  who  as  you  are  aware  is 
currently  absent from  work following  surgery. 
  is  not expected  to  return  to  work  until 
after the date when  a  response  is  due to  your PDF  report.  In  any event,  I am  able to address 
the  matters  identified  within  your  PFD  which  have  relevance  to  Wakefield  Council  and  as 
detailed to you  in evidence by me at the inquest on  17th  January 2023. 

Context of Wakefield Council's involvement at Inquest 

Following request by letter dated 9th  January 2023 received  on  10th  January 2023 for a Council 
Officer  to  attend  the  Inquest  on  Monday  16th  January  to  give  evidence,  Wakefield  Council 
 dated 12th January 2023 [Annex 1] which gives 
provided a copy of the statement of
context  to  this  response  to  your  PFD  report.  Wakefield  Council  additionally  provided  to  you 
information in  a Note on  1?lh  January 2023 . 

Much of the  PFD  report identifies national issues and  so this response only addresses matters 
where Wakefield Council has relevant information in respect of the matters of concern you have 
raised . For ease of reference , we have responded to each of your concerns in red within the text 
of your PFD  report copied  below. 

 
 
 
 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: 

1.  Considerations regarding the field where the fatality occurred. 

1.1. In an  incident on 29 September 2020 Mr Holmes died after being trampled  by cattle.  His wife 

sustained major spinal and other injuries.  It was a catastrophe for their family.  The couple were 
walking on a public footpath which  ran through the middle of a large field.  It occurred as they were on 
a  lunchtime walk at a time when they were working from home due to the Covid pandemic. 

1.2. Statistics from the  Health & Safety Executive ('HSE') indicate that on  average 6  people have died 

each year from injuries sustained  in  cattle trampling  incidents.  11  people died in 2020, one of whom 
was Mr Holmes.  Such incidents are avoidable if walkers and cattle are separated.  In  my judgment, 
this unacceptable situation  necessitates a review of the arrangements in which walkers are brought 
into contact with cows and their calves,  by virtue of rights of way. 

1.3. The field  in which the incident occurred (the 'incident field')  had  been used to graze cattle for over 50 

years.  The public footpath  had existed since the National Parks & Access to the Countryside Act 1949 
recorded its existence.  The logic for the  precise path through the incident field has been  lost in  the 
mists of time. 

Response: 

It is not uncommon for public rights of way to follow the most direct route from points A to B across the 
countryside,  including through farmer's fields,  such as 
the "incident field".  Convenient use public rights of way is one of the key aspects embedded in the 
Highways Act 1980, for example an application under Section  119 of the Act to deviate the route of a 
PROW could fail  if the alternate route would cause substantial inconvenience to  its users. 

1.4. Following the fatal  incident,  the farmer made a formal application dated  12 January 2021, to divert 
the public footpath to the edge of the incident field and erect a suitable fence,  so as to create a safe 
corridor which separates walkers from the cattle (the 'application').  All the witnesses who gave 
evidence at the 
inquest endorsed the wisdom of the application.  One described it as "essential." 

Response: 

On the 1 October 2020, the HSE issued a prohibition  notice [P/ST/30092020/1].  It prohibits the 
grazing of cows with calves in  fields with  public access because they are not segregated from the 
public when  in these fields.  Before
public rights of way, 

 must take steps to protect members of the  public from attack. 

 cows with calves back into the fields with 

 releases 

This Prohibition remains in  place.  In  respect of the field where Mr Holmes was killed,  if 
 is 
to use field  5357 for grazing cattle,  then  the footpath  and walkers using it are protected from grazing 
cattle by an electric fence.  This was confirmed  in  evidence by Principal HSE Inspector 

1.5. As objections have been  lodged to the application,  the matter must be resolved  by way of a public 

enquiry.  The Secretary of State is asked to ensure the decision maker in  such a process is aware of 
the unanimous views expressed in 
the course of the inquest. The application may well eliminate altogether the risk identified in the incident 
field. 

 
 Following this incident,  in January 2021 
 applied to the Council pursuant to s119 
Highways Act 1980 to divert three public footpaths in  Hollinghurst Farm that passed through fields that 
were used for grazing cattle,  including Sitlington 35. 

The application was made in  the "interests of the owner" to enable best use of the grazing  land whilst 
separating the public from the cattle. 

The Council made 3 Diversion Orders on 8 March 2021 

One of the Orders [Annex 2] relative to the PROW through the incident field  had 5 objections and work 
was done to address these. Two objections relating to the incident field  PROW have not been 
resolved. 

Where there are unresolved objections,  the Council must refer the Order to the Secretary of State 
who will appoint an Inspector to consider the Contested Order and whether to  confirm the diversion or 
not. 

The final decision maker on confirmation of the Order is the Inspector appointed by  the Secretary of 
State. 

If the Contested Order is confirmed,  the right of way will  be diverted. If the Order is  not confirmed the 
right of way will  remain on  its current alignment. 

However,  the Prohibition  remains in  place.  In  respect of the field  where Mr Holmes was killed,  if 

 is to  use field  5357 for grazing cattle,  then the footpath  and walkers using it are protected by 

an  electric fence.  This was confirmed in  evidence to be the position  by  Principal HSE Inspector 

It is likely that there will  be  a public inquiry,  hearing,  or written  representations,  to enable an  Inspector 
to  make their decision in  respect of the contested  Diversion Order.  Wakefield Council has suggested, 
considering the nature of the two remaining  objections,  that it believes the  Planning Inspector could 
resolve the matter though written  representations and without the  need for a public inquiry. 

The Contested Order, and all associated documents,  have been sent to the Secretary of State with the 
Council's request that the Order.  There is a backlog within the  Planning Inspectorate in  respect of 
Diversion of rights of way. 

Public Footpath Sitlington 35 - Diversion Application and Order Timeline 

Site meeting attended by PROW Officers and landowner to discuss 
possible diversion  of footpath. 

15 December 2020 

Informal consultation  undertaken on: 

8 January 2021 

 applied to the Council to divert public footpaths at 
Hollinghurst Farm that passed through fields that were  used  for grazing 
cattle. 

Orders made on: 

Orders advertised: 

Objections received within statutory notification period 

2 Outstanding objections (concerning various aspects of 
new route and a preference for the diverted path to take another route) 

12 January 2021 

8 March 2021 

18th  March 2021 

 
 
 
 3 objections made and then subsequently withdrawn 5 
representations in  support received 

Unconfirmed Order for which objections remain submitted to  Secretary 
of State for determination. 

3 January 20231 

1 I apologise to HMSC as in the material provided to the court we had detailed in error that the 
submission had been made to the Secretary of State in March 2022. 

Subsequent to the inquest concluding, on the 23rd  January 2023 
Way Officer with Wakefield  Council  updated the planning  inspectorate in  respect of the inquest 
outcome by  email,  provided  the  Record of Inquest and  requested an  update as to  the application to 
the  Planning  Inspectorate and confirmed that he would  provide the  PFD report once it had  been 
provided to Wakefield  Council and  requested: 

 a Public Rights of 

"Any means of expediting this case that is available to  the  Inspectorate would therefore be 
appreciated.  Wakefield Council would be happy to make its case by written representations if the 
Inspector is  minded that this is appropriate." 

A  response to this email was received  on 24th  January 2023 from 
Caseworker and Charting - DEFRA Team of the Planning Inspectorate. 
 confirmed that 
the email and the Record of Inquest had  been  added to the file and that he would  look for the file  in 
the backlog of case. 

 - Rights of Way 

On  the 26th  January 2023, 
 that:  "We have 
recruited 4 new case officers who start in  early February 2023 which  will mean our backlog will 
eventually reduce.  However,  taking training and since they will be lower at the start of employment into 
account,  my  estimate is that it is  unlikely to  be  actioned before Easter.  If your Council wishes to make 
a case for this Order to be expedited and for it to be processed as soon as possible you can  write to 
me with  your reasons." 

 confirmed  by email to 

On the 27th  January 2023, 
highlighted Section  5 and sub section  1.5 of the  PFD  report detailing  HMSC's concerns and 
requested that:  "As a result of the specific concerns raised in  the  Coroner's report we confirm that we 
would wish for this Order to  be determined at the  earliest possible time." 

 provided the  PFD  report to 

 by  email and 

On the 30th  January 2023, 
expedited. 

 acknowledged and  noted the request for the Order to  be 

On the 28th  February 2023, 
finalising this response to the PFD report and asked:  "Further to  my email in January are you able to 
give us any further information on  the timetable for determination of the  Order? Anything further you 
are able to tell us would be appreciated and enable us to respond to  the  Coroner as accurately as 
possible." 

 confirming that the Council was 

 emailed 

 responded  by  email the same day confirming:  "We have recently recruited 4 new case 
officers to replace staff who  moved on  during and since lockdown with  the aim of bringing down  the 
backlog of cases to  start.  They are currently in  training so it may be 4-5 weeks before we start to see 
results.  Currently the oldest cases I have are from  Marchi April 2022.  As the  Order was received in 
January 2023,  there are 9 months of older cases before it.  I am hopeful that this Order will have been 
started within 4 months as opposed to  9." 

On the 1st  March 2023, 
expedited: 

 emailed 

 and requested again the decision to be 

"We  appreciate the situation concerning backlog and timescales however,  we again request for 
special expedited consideration of this case.  This is further to the  Coroner's view as detailed in 
the  Prevention of Future Death report,  that the  Order "may well eliminate altogether the risk 
identified in  the incident field''. 

Wakefield Council will provide this response and the PFD report to 

 so that he 

 ensures the decision maker allocated to consider the Order is aware by this response of what is 
described by the Senior Coroner as:  "the  unanimous views expressed in  the course of the 
inquest" and that in  the Senior Coroner's view,  "The application may well eliminate altogether 
the risk identified in  the incident field." 

2.  The general position in  relation to dogs on Rights of Way 

2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common 

factors in  trampling  incidents are cows with calves and walkers with dogs.  Mr & Mrs  Holmes 
had two dogs on  leads at the time. The inquest heard evidence about four previous 
incidents in  the incident field,  three of which  involved walkers accompanied by dogs.  There 
appears to be a strong correlation  between trampling incidents and walkers with dogs. 

2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well,  particularly 

when the calves are young . 

2.3. Evidence was given at the inquest to the effect that dogs are regarded  as a 'usual 

accompaniment' and are thus entitled to be  brought onto a Right of Way.  This proposition 
lacks clarity.  There is also uncertainty as to whether dogs are required to be on a lead when 
on  a public footpath. 

Response: 

These are identified as national issues requiring  consideration and  response by the Secretary 
of State and wider engagement with key stakeholders. Wakefield Council,  as with  other local 
authorities,  is a creature of statute where its authority and powers arise from a statutory 
framework.  In  the case of Public Rights of Way (PROW), these statutory duties and powers 
arise from the  Highways Act 1980 and  any associated case law.  It is  proposed that Wakefield 
Council could  not act in  isolation without a change in  the legal framework within which the 
Council operates. 

Wakefield  Council  confirmed  in  evidence to the  inquest that dogs are considered  and  regarded 
as  a  'usual  accompaniment'  on  a  PROW  and  therefore  dogs  are  permitted  to  with  be  a 
keeper/controller on a PROW. 

Although  legislation  does  not require that dogs  be on  a  lead  whilst on  a public right of way,  the 
owner must ensure that they are fully  in  control of the dog at all times. 

The dog is  not entitled to roam away from the path and  if it does so,  the owner could  be  guilty of 
committing trespass against the landowner. 

The Dogs (Protection of Livestock) Act 1953 makes it a specific offence to allow a dog to  be at 
large in  a field or enclosure where there are sheep,  and a farmer may have a defence in any 
civil  proceedings for killing  or injuring a dog which is caught worrying sheep. 

In  short,  the walker with  dog must ensure their dog is under close control  near livestock and if 
the owner has any doubts at all about their ability to control their dog they should  keep  it on a 
lead. 

The one exception to this rule  is if the dog walker is in  a field  with cattle, especially with calves 
where the general advice is that if cows become aggressive towards the walker and their dog 
stay calm and  let the dog off the lead. 

2.4. Consideration should be given  in  the HSE Information Sheet to a clarification of the legal 

position of dogs brought onto rights of way where it is foreseeable they will  interact with 
cows and their young calves 

Response: 

This is  identified as a national issue requirinq consideration and  response bY the HSE. No 

 action  is proposed  by Wakefield Council in  the absence of a change to the statutory framework 
within which  it operates. 

However,  as was the clear evidence at the inquest,  including in  submissions by 

the duty holder,  i.e.  that of the farmer to control the risk presented  by  cattle and  calves to 
members of the public undertaking their right to use the PROW. 

 who confirmed  that the obligation  under health and safety law,  is on 

As I detailed in  evidence,  it is for landowners,  managers, owners and occupiers of the land to 
risk assess activities being conducted by them on their land  and any attendant risks their use 
of their own  land could pose to members of the public exercising their legal rights to walk on  a 
public right of way 

3.  The power to restrict dogs on public footpaths, at certain times. 

3.1 . It is difficult to predict whether a particular cow will  react aggressively to the presence of 
a dog in  a field.  It was suggested during the inquest, the risk of such a reaction  is highest 
in  the months after the birth of a calf. 

3.2. To neutralise this risk,  consideration should  be given to  empowering  Local Authority 

Footpath officers (on  an  application  made by a farmer in  relation to an  identified field),  to 
prohibit dogs being taken onto the field  for a specified period.  In  short,  a temporary 
prohibition order.  The rationale for a temporary expedient of this nature is the  imperative 
to  protect the safety of the public,  when  set against the  relatively brief interference with 
any right a walker may  have to be accompanied by a dog 

Response 

This is identified as a national  issue requiring  consideration and  response by the Secretary 
of State having identified that it would require statutory change.  No action is proposed  by 
Wakefield Council  in  the absence of change to the statutory framework within which  it 
operates. 

3.3. An  alternative approach would  be to authorise landowners to post notices at the 

entrance to particular fields,  alerting walkers to the presence of cows with young  calves 
and advising them not to  bring dogs into the field  (whether on  a lead or not) between 
specified dates.  The objective of preventing harm may not,  however,  be achieved if 
walkers ignore the advice or the suggested  signs are vandalised. 

Response: 

This  is identified as a national issue requiring  consideration and response by  the  Secretary 
of State having identified that it would require statutory change.  No action is proposed  by 
Wakefield  Council  in  the absence of change to the statutory framework within which  it 
operates. 

3.4  It is acknowledged that statutory change would  be  required to create powers of this 
nature.  The Secretary of State will doubtless reflect upon the balance to  be struck 
between the imperative of protecting the safety of the public and  the relatively brief 
interference this would impose on  the right of walkers to bring their dog into any field 
affected.  It should also be borne in  mind that the people whose safety is currently 
jeopardised under existing arrangements are the dog walkers themselves. 

Response: 

This is identified as a national Issue requiring consideration and  response by the Secretary of 
State.  No  action  is  proposed  by  Wakefield  Council  in  the absence of change  to  the statutory 
framework within which  it operates. 

4.  The role of public bodies. 

4.1  The current potential for a hazard to be created  by walkers on  public footpaths moving 
in proximity  to  a farmer's qrazinq cattle,  requires management of these com peting 

 
 interests.  It was contended at the inquest that the farmer is subject to a statutory duty 
to carry out a risk assessment in  accordance with the Management of Health & Safety 
at Work Regulations  1999.  It was contended that a landowner must  conduct his 
business around the existing public footpath , irrespective of which came  into existence 
first.  Whilst not disputing the legal duty imposed on  a farmer in  these circumstances, 
the  potential mischief left unguarded in  that analysis,  is that Small & Medium 
Enterprises (SME's) such as small family farms may lack the expertise to recognise 
the problem, carry out an  effective risk assessment in  relation to cattle trampling risks 
and  devise reasonably practicable control measures. 

4.2.  To  avoid the harm envisaged  by  further deaths in  comparable circumstances, the 

HSE and  Local Authorities should explore ways to apply their expertise in 
collaboration with  landowners ( of the type involved in  this inquest), whether on a paid 
or voluntary basis. The maintenance of safe public rights of way could  be said to 
require oversight and management by  public bodies as well as the landowners 
concerned. 

Response: 

This is a national Issue that would require response by the Secretary of State and the HSE. 
No action  is proposed by Wakefield Council in  the absence of change to the statutory 
framework within which  it operates. 

It is  proposed that the  hazard is created by the presence of the cow with calves in  the vicinity 
of members of the public, thus creating a risk to their safety. It is for landowners, managers, 
owners and occupiers of the land to risk assess activities being conducted by them on their 
land and any attendant risks their use of their own  land could  pose to  members of the public 
exercising their legal rights to walk on  a public right of way.  The responsibility  is the duty 
holders and  not that of the  HSE or local authority. 

To  suggest  that  the  HSE  and  LAs  could  apply  their  expertise  to  landowners  on  a  paid  or 
voluntary basis would not be workable and could be said to dilute the responsibility of the duty 
holder.  Advice on  how to  assess and  manage risk is provided through  the  HSE and as with 
any other business it is incumbent on the duty holder to  manage those risks. 

Oversight and  management by  public bodies as well as the landowners concerned is not the 
current position and would  be unworkable. A  public body cannot be expected to  know what 
landowners are doing on their land  from  hour to hour or day to day,  which  is why the 
obligation  is  placed on the duty holder to risk assess activities being conducted by them on 
their land and  any attendant risks their use of their own  land could  pose to members of the 
public exercising their legal rights to walk on  a public right of way. 

4.3  One example of pragmatic help to eliminate cattle trampling  risks would  be for the 
HSE to draw attention to the process available under section  119 of the Highways Act 1980 
to apply for a public footpath to be re-routed , so as to separate cows with calves and 
walkers.  Consideration could  be  given to highlighting this option  in  a  future edition of the 
HSE Information Sheet. 

Response: 

This is a national  Issue that would  require response by  the HSE. No action  is  proposed by 
Wakefield Council in the absence of change to the statutory framework within which it 
operates. 

A Diversion Order application process takes time and has regard to the test contained in 
s119 Highways Act,  "in the interests of the owner, lessee or occupier of land crossed by 
the path ... it is  expedient that the line of the path or way or part of that line should be 
diverted. " 

The duty holder's health and safety  responsibilities are quite separate and clear.  A 
landowner,  lessee or occupier of land  is well  aware of a public right of way on  their land  and 
that at an y time a  member of the  public mav be present on  the  PROW exercisin g their legal 

 right.  It is for the landowner therefore to ensure that by their use of the land they do  not 
create risks to those members of the public exercising their legitimate rights to walk over the 
PROW. 

4.4  This report will be sent to special interest groups thought to have an  interest in  this issue, 
in the hope of enlisting their assistance in  educating all who use the countryside in  relation to 
the risk and the ways in  which  it could  be eliminated. 

Response: 

Engagement with wider stakeholder groups on  this issue is welcome. 

I trust this information is of assistance to you.  Please do not hesitate to contact me if you require 
any further assistance. 

Yours sincerely 

Service Director Environment, Street Scene & Climate Change 

cc. 
Inspectorate by email 

- Rights of Way Caseworker and Charting - DEFRA Team. The Planning

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