Prevention of Future Deaths reports · 2023

John Wrigley

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 report29 Sep 2023
Reference2023-0359
DeceasedJohn Wrigley
CoronerSabyta Kaushal
Coroner areaDerby and Derbyshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

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

Responses

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

Response from Motorsport UK Association Limited (PDF)
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

Related reports

Other reports by Sabyta Kaushal

See all →

More reports categorised “Road (Highways Safety) related deaths”

See all →

Track Road (Highways Safety) related deaths

See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.