Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0359, written 29 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2023 |
|---|---|
| Reference | 2023-0359 |
| Deceased | John Wrigley |
| Coroner | Sabyta Kaushal |
| Coroner area | Derby and Derbyshire |
| Category | Road (Highways Safety) 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS
NOTE· This form is to be used before an inquest
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
1 CORONER
I am Sabyta Kaushal, Assistant Coroner, for the coroner area of Derby & Derbyshire.
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
On 06 May 2021 I commenced an investigation into the death of John Frederick WRIGLEY
aged 60. The investigation has not yet concluded and the inquest has not as yet been
concluded.
4
CIRCUMSTANCES OF THE DEATH
John Wrigley was an experienced Superkart racer who had been involved in motor sport for
over 20 years. On 3rd May 2021 he attended an event at Darley Moor Kart Circuit. During a
qualifying session, his kart left the track (reason unknown), travelled across wet grass and
the left front wing of the kart impacted with a lorry tyre wall at between 66 and 71 mph. The
kart rotated 360 degrees, then impacted on the left rear side wing and came to rest on the
opposite side of the track. He was subject to huge forces and was flung out of the kart and
landed on the track. There was no contact with any other Kart. A Marshall and another Kart
racer witnessed the collision. Mr Wrigley received immediate medical care for his severe head
injury and was taken to Derby Royal by land ambulance where he was pronounced deceased.
His injuries were consistent with a high-speed impact.
Police were not contacted initially. Following police involvement, police were in touch with the
Motor sport association who had primacy to investigate the circumstances with police
assistance.
Following the post mortem the medical cause of death was determined to be:
la. Head Injury
5 CORONER'S CONCERNS
During the course of the investigation my inquiries 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:
(brief summary of matters of concern)
1. The lorry tyre boundary wall remained in position on impact, moving only a few millimetres
backwards; it did not absorb enough energy to slow the velocity of the kart. The lorry tyre
barrier did not dissinate enern"; evidence nrovided bv those investinatino the circumstances
Regulation 28- Before Inquest
Document Template Updated 30/07/2020
indicated that the primary function of the tyre barrier is to protect what lies outside the track
e.g spectators and to contain the vehicle within the confines of the track.
Energy dissipating or impact absorbing protection such as Airfence/Recticel - a closed cell
barrier - was available to be placed in front of the tyre barrier but was not utilised ; the view
was that shallow angle contact with a closed cell foam barrier would result in 'pocketing' i.e.
cause injury rather than mitigate it.
Super karts are not fitted with. safety belts. This aspect, racer error and an inability to control
the kart following such an error and loss of control was not taken into account when decisions
were made regarding the placement of additional impact absorbing protection.
Urgent action is required to review what additional type of energy dissipating or impact
absorbing protection (e.g Airfence/Recticel) should be placed in front of the tyre barrier,
where and in which circumstances. All risks, no matter how minimal, should be taken into
account.
Additional protection was available but not used. It may have reduced the potential severity
of such an incident and prevented the death of a competitor or racer.
2. It had been raining and although water was not pooling on the track (which would have
been a visible indicator to consider stopping racing on safety grounds) the grass area
adjacent to the track was wet such that when Mr Wrigley le~ the track and moved onto the
grass, the wet grass caused his kart to accelerate and collide with the tyre wall.
Insufficient regard was given to the fact that the grass was wet when deciding if competitors
should be allowed to use the track. Racer error and an inability to control the kart following
such an error and loss of control onto grass was not taken into account when decisions were
made regarding the use of the track by competitors. Urgent action is required to review the
risk assessment of whether to start or stop a race due to wet weather.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (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 November 23, 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
I have also sent it to
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 vour response bv the Chief Coroner.
Regulation 28 - Before Inquest
Document Template Updated 30/07/2020
9
29~~
Sabyta Kaushal
HM Assistant Coroner
Derbv & Derbvshire
Regulation 28 - Before Inquest
Document Template Updated 30/07/2020
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.
IN THE MATTER OF: John Wrigley (deceased) – incident at Darley Moor Circuit 3 May 2021 And IN THE MATTER OF: Regulation 28 Report to prevent future deaths dated 29 September 2023 RESPONSE OF MOTORSPORT UK ASSOCIATION LIMITED (‘MOTORSPORT UK’) 1. This is the Response of Motorsport UK to the Regulation 28 Report dated 29 September 2023 under the hand of Ms Sabyta Kaushal, HM Assistant Coroner Derby & Derbyshire (‘HMC’) (‘the Report’). The Report was addressed to Both are senior members of staff at Motorsport UK. and is a non-practising solicitor and is the Regulatory Counsel and Disciplinary Officer. is an engineer by background and is in the Safety Executive role at Motorsport UK. 2. Motorsport UK is recognised by UK Statute as a body Authorised to Permit motor sport competitions in the jurisdiction of the Court (and elsewhere) and further is recognised as the National Governing Body of 4+ wheel motorsport in the UK by Federation Internationale de l’Automobile, (‘FIA’) the World governing body of 4 + wheel motorsport, pursuant to the Statutes and International Sporting Code of FIA. Motorsport UK is a Founder Member of FIA and is placed by its representatives and nominees on the World Motorsport Council, the International Tribunal, the International Court of Appeal and across the several sporting Commissions of FIA. 3. This Response is necessarily affected by the fact that HMC has not concluded the Inquest to which the Report is related. The last Hearing of the matter at which live and other evidence was received, was 16 December 2022 and which was adjourned for further evidence which has been provided. HMC has additionally demanded other material, to which it is argued she is not entitled as it concerns unrelated matters. Those requests are the subject of legal correspondence in which HMC’s latest 1 response was received on 21 November 2023 and which invites a response by 4 December 2023. The Inquest is listed to resume at a concluding hearing on 11 December 2023. References below to Evidence received are to that variously given at the Hearing 16 December 2022 (‘the first hearing’) and thereafter to date. 4. Regrettably, HMC appears to have misunderstood the Evidence. 5. All circuits Licenced for Regulated motor sport by the Statutorily recognised authorised bodies - Motorsport UK and the AutoCycle Union (“ACU”) in this case - rigorously apply the application of and requirement for appropriate barriers to be positioned at relevant locations and the types of which depend on the various track features (simply expressed as straights or corners). 6. The Evidence provided to HMC at the first hearing included that of an acknowledged and internationally recognised Expert Track Inspector certified in the approval of circuits, including barriers, in the territories of FIA (including this jurisdiction) ( ). His evidence is that the barriers in place in this instance were appropriate. Moreover, ’ evidence is that the tyre barrier referred to did absorb energy, which in turn was evidenced by the movement of it. It is a matter of physics. 7. The global standards applied to course design and regulated inspection have rejected the use of Recticel (or similar other brands such as Airfence referred to by HMC) on straights because of the risks of pocketing associated with it. It is however deployed in relevant circumstances i.e. at corners where there is a ‘head-on’ risk. 8. The risk of pocketing has been referred to and acknowledged by HMC in the Report but, without any scientific premise, she has apparently rejected the views of experts. 2 9. Barriers cannot absorb all energy applied to them. As offered in evidence at the first hearing and as recognised by HMC, barriers are intended primarily to keep competing vehicles within the course and thereby avoiding risk to persons outside the course. 10. Thus the underlying premise of paragraph 5.1 of HMC’s Concerns cannot be accepted. There is no scientific basis or reference for the observations made. It fails to take into account the expert evidence which the Court received on the issue at the first hearing. It will be noted that despite extensive enquiry by local authority officers at the instruction of HMC, no other expert evidence was commissioned or called at the first hearing. 11. Regarding HMC’s observations at paragraph 5.2 of the Report, we note HMC’s comments regarding features between the track and barriers, in particular in this case wet grass. We unavoidably but respectfully comment that HMC’s averment that ‘.. wet grass caused his kart to accelerate and collide …’ is simply, and scientifically wrong. The fact of the grass being wet could not cause the kart to accelerate without additional force being applied to the kart. Its retardation qualities may be reduced compared, for example, to dry grass or some other surface, but it cannot cause objects to accelerate. 12. HMC’s comments regarding risk assessment in wet weather is noted, however that is already undertaken by highly trained and licenced officials at each Event as stated in Evidence at the First Hearing. As those assessments are already a mandatory part of Regulated motorsport, no further action is required. 13. Of concern however is the premise of the comment at paragraph 5.2 because it suggests at one possible level that whenever grass is wet competition should be abandoned. However, grass may be ‘wet’ for any number of reasons, even in otherwise dry weather depending on the time of year, including when freshly cut or dewed. At 3 another level HMC appears to opine that no competitive sport should occur whenever it is wet. That appears to be unrealistic in the latitudes of the UK. 14. Accordingly, in managing the obvious risks voluntarily accepted by written indemnity by all participants (such as and including Mr Wrigley) under the contractual Regulations of the sport, this ASN as with the other relevant Statutory authorities, requires the deployment of appropriate and suitably installed barriers at relevant locations on all Licenced courses and which is manifested by the recognised Statutory bodies granting Track Licences pursuant to the dynamic review of them by qualified experts. 15. Where relevant to the nature and type of the competition, the course will also benefit from inspection and if satisfied the grant of a Track Licence by the FIA (for cars) and/or the FIM (for motorcycles and sidecars). Note, Darley Moor is not a venue which has ever been used for FIA or FIM Permitted events. 16. All tracks and courses are inspected by vastly experienced qualified engineers variously employed by the Statutory authorities or the FIA/FIM where applicable. Those inspectors are fully conversant with the relevant laws of physics and the nature of the relevant competition vehicles and the nature of competition and associated risks. 17. All risk cannot be removed and participants freely acknowledge that. 18. This ASN as a Statutory authority has historically, and continues currently to collaborate nationally with other National Governing Bodies, and with the HSE on all such matters. Our contribution informs both the HSE’s knowledge and published guidance including HSG112 and the deployment of suitably installed and appropriate barriers as stated above, and is part of a working group in relation to such matters. 4 REGULATORY COUNSEL MOTORSPORT UK 23 November 2023. 5
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