Christopher Townsend

Response to the Coroner's Regulation 28 Report to Prevent Future Deaths 

1 

THIS RESPONSE IS MADE ON BEHALF OF 

Auto Cycle Union Limited ('ACU') 

2 

REGULATION 28 REPORT 

This response follows a report by HMAC James Puzey. For ease of reference, sections 
3 to 5 below are copied from the Coroner's report. 

3 

INVESTIGATION and INQUEST 

On  22  June  2023  HMSC  David  Reid  commenced  an  investigation  into  the  death  of 
Christopher William Townsend,  aged 43. The investigation concluded at the end of the 
inquest  on  5  April  2024  which  I  heard.  The  conclusion  of  the  inquest  was  that  the 
medical  cause  of  death  was  pneumonia  as  a  result  of  multiple  injuries  sustained  in  a 
motor cycle accident and that Mr Townsend died as a result of an accident. 

4 

CIRCUMSTANCES OF THE DEATH 

Christopher  William  Townsend  died  on  8  June  2023  at  the  Queen  Elizabeth  Hospital, 
Birmingham. He was involved in a motor accident on 4 June 2023 whilst participating in 
an organised grass-track motor-cycle and side-car race. He sustained multiple chest and 
abdominal injuries from which he did not recover 

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)  The risk assessment prepared for the grass-track event on 4 June 2024 was a 
downloaded proforma from  the ACU publication “ACU Requirements for Safety 
Precautions At All Track Race Events Held Under An ACU Permit” (p.19 of 26). 
This  document  listed  pre-populated  control  measures  to  address  a  list  of  pre-
populated risks. The control measures were ticked “yes” or “no” by the organiser 
to indicate whether they were in place. The assessment of the level of that risk 
as  high,  medium  or  low  was  also  pre-populated.  This  did  not  amount  to  a 
process  that  could  produce  an  event  specific  risk  assessment  nor  did  it 
encourage organisers to record meaningful conclusions about controlling risk at 
their  event.  I  was  told  by 
  that  this  was  a  pro-forma  for  grass  track 
events and that more complex, event specific risk assessments were produced 
for other types of event.  He also confirmed that the risk assessment pro-forma 
were under review by the ACU and he produced an example of a potential new 
pro-forma requiring significantly more individual assessment and input. I accept 
that the ACU is taking steps to address the inadequacy of the grass track event 
risk assessment process. 

(2)  However, in my questions to 

 he confirmed that there is no requirement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 for  organisers  of  events  held  under  the  ACU  Regulations  to  prepare  an  event-
specific  Safety  Plan  at  either  National  or  Club  events.  There  is  such  a 
international/European  permit 
requirement 
for  ACU  events  held  on  an 
(paragraph 3.26 National Sporting Code 2023).
confirmed that whilst it 
is not an ACU requirement to prepare such a plan for Club/National events it is 
open  to  organisers  to  do  so.  Appendix  3  of  the  ACU’s  publication  provides  an 
example of contents list of an event safety plan. 

(3)  Planning  for safety  at  motorsport events  to which the public  are  admitted must 
be  thorough,  comprehensive  and  verifiable  by  being  recorded.  This  allows 
organisers to record and disseminate safety arrangements for their events. The 
risks may differ in scale, but not substantially in nature, as between international 
and national/club events. 

(4)  In my opinion, in the absence of such methodical planning and recording there 
is  a  risk  of  future  deaths  arising  from  the  current  arrangements  for  safety 
planning at ACU track race events. 

(5)  I have carefully considered

evidence as to the reviews that are being 
undertaken by the ACU of their procedures and guidance. This was provided in 
his  written  evidence,  his  answers  in  oral  evidence  and  in  the  letter  from  him 
dated 5 April 2024. I have also carefully considered the cogent submissions on 
behalf  of  the  ACU  by 
  of  DWF,  in  particular  as  to  Chief  Coroner’s 
thereof. 
Guidance  Note  5 
Nonetheless, I remain of the opinion that in the absence of a requirement for a 
recorded safety plan for each event there is a risk that future deaths will occur. 

(November  2020),  especially  paragraph  7 

(6)  Since  the  inquest 

  has  provided  me  with  statistics  of  injuries  and 
fatalities at events governed by ACU rules and procedures. It does not allay my 
concerns but rather confirms that serious injuries and fatalities do occur at these 
events not infrequently. 

6 

ACTION TAKEN 

 explained that safety planning was required for all ACU permitted 
In evidence,
events;  however,  the  information  was  spread  across  a  number  of  documents.  For 
example, it was explained that the Supplementary Regulations that are prepared before 
an event detail a number of matters relating to safety. 
 accepted that a recorded 
safety plan is required for some events, and that he would ask the Board of Directors to 
consider making this a requirement for all ACU permitted events. 

The ACU's Board of Directors have considered the concerns raised and will ensure that 
a document entitled Safety Plan is a requirement for all ACU permitted events from the 
start of the 2025 season. The content of the Safety Plan will continue to be discussed by 
the relevant people within the ACU to ensure that comprehensive guidance is provided 
to event organisers in readiness for the 2025 season. 

7 

SIGNED 

On behalf of Auto Cycle Union Ltd 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 8 

DATE OF RESPONSE 

16 May 2024