Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0587, written 25 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2024 |
|---|---|
| Reference | 2024-0587 |
| Deceased | Natasha Johnston |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Accident at Work and Health and Safety related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of Natasha Johnston A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Home Department Council , The Secretary of State for the , The Chief Executive Officer of Surrey County 1 CORONER Richard Travers HM Senior Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into the death of Natasha Johnston was heard and concluded on the 21st October 2024. The medical cause of Ms Johnston’s death was: 1a: Shock and Haemorrhage including Perforation of the Left Jugular Vein 1b: Multiple Penetrating Dog Bites to Neck, Arms and Torso 4 CIRCUMSTANCES OF THE DEATH In the early afternoon of the 12th January 2023, Ms Johnston was walking some eight dogs in the area of the ‘Viewpoint’, Gravelly Hill, Caterham, Surrey. The dogs ranged dramatically both in size and RT3589 1 weight, from small to very large. She was in the habit of acting as a dog walker and had walked these same dogs on previous occasions without difficulty. Between approximately 14:00 hours and 15:00 hours she was seen in the area, by a number of different people. Initially, she appeared to be in control of the dogs, but as time went by, the dogs became increasingly excited and out of her control. At one point she was seen by another dog walker with a large group of dogs. He had seen her before with a lot of dogs and, as before, on seeing him she immediately turned around called the dogs and went in the opposite direction with the dogs following. Another person, who was out exercising, saw her with a large number of dogs. He stood to one side to allow her to pass and one of the larger dogs jumped up at him and put its paws on his chest, albeit causing him no harm. At another point, two riders came across her, at that time she was sat on the floor surrounded by a group of dogs, their leads were all tangled up. She shouted, ‘go back, go back’. The dogs were not attacking her, but they were out of control. Two of them ran towards the horses frightening them and causing one of them to bolt with the result that its rider was thrown to the ground. After this, one of the larger dogs, began worrying a smaller dog that was being walked by its owner. On picking up her dog, the owner was then bitten in her left buttock, by this dog, causing her severe pain and injury. By the time of the last two encounters, the dogs were no longer in Ms Johnston’s control. A short while later, another walker’s attention was drawn, by a fellow walker, to a large number of dogs that were all off their leads and causing a commotion. On going to investigate he saw an object at the bottom of a nearby very steep slope. He descended the slope to see two of the dogs with blood on their muzzles in the vicinity of the object, which, as he approached, he recognised to be the body of a woman, this was Ms Johnson. Despite the aggressive stance of the dogs, he approached Ms Johnston, who was covered in blood and had suffered a large number of puncture wounds. He could not find any signs of life, but called the ambulance service and, under their instruction, began CPR on Ms Johnston. Despite his attempts and those of two police officers and a paramedic, Ms Johnston remained unresponsive. Ms Johnston’s death was recognised at 15:29 that same day; she had died from her wounds. It was clear that she had been the subject of a vicious dog attack by an unknown number of dogs, which had formed part of the group of eight dogs that she had been walking that day. The post mortem examination revealed that she had sustained multiple injuries consistent with dog bites and claw marks. The concentration of RT3589 2 bite marks was particularly severe around the neck. They had led to the penetration of the jugular vein, which in itself would have been fatal. However, the remaining bite marks would also have led to catastrophic haemorrhage which would also have resulted in her death. There were no other injuries that could have caused or contributed to death. Whilst, when she was first seen, Ms Johnston appeared to have some control over the dogs, it was readily apparent that as time went by that any such control was lost, eventually with a tragic result. Bearing in mind the sheer number and size of the dogs involved, her inability to control and to hold them was not surprising. I heard evidence that, whilst there maybe guidance available as to the maximum number of dogs a person should walk on their own in a public place, there is no actual restriction on the number or size of dogs that a person can walk on their own in a public place, either locally or nationally. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are as follows. – 1. The lack of regulation, both locally and nationally, that restricts the number and weight of dogs that an individual person can walk on their own in a public place. 2. Consideration should be given to limiting the number and gross weight of dogs an individual person should be allowed to walk in a public place, both for their own safety and for the safety of others. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that those people identified in the first section of this report have power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. RT3589 3 Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner. 1. 9 Signed: Richard Travers DATED this 25th October 2024 RT3589 4
2 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.
Richard Travers HM Senior Coroner for Surrey HM Coroner’s Court Station Approach Woking GU22 7AP Dear Mr Travers, Seacole Building 2 Marsham Street London SW1P 4DF T: 03459 33 55 77. Date: 30 April 2025 We are writing to you in response to the ‘Regulation 28 Report to Prevent Future Deaths’, which followed the inquest into the death of Natasha Johnston from a dog attack, which was a tragic event and our sympathies go out to those affected. Our team received your Regulation 28 report, addressed to the Secretary of State for Environment, Food and Rural Affairs, on 5 March 2025. We would like to thank you for your recommendations for the prevention of future deaths resulting from dog attacks. We note in particular your concern that there is no national regulation regarding the maximum number or size or weight of dogs to be walked by an individual. We have set out below the existing regulatory requirements and our plans for future action in this space. Overview of current regulatory regime and guidance for dangerous dogs and dog walking in England and Wales There are currently no national regulations restricting the number, size or weight of dogs walked by individuals. However, there are broad powers in place to tackle dangerous dogs at a national level. Under the Dangerous Dogs Act 1991 certain dangerous breeds or types can be banned in England and Wales, which will require dogs of those breeds or type to be kept on a lead and muzzled at all times when in public. There are currently five banned breeds or types of dog in England and Wales: the XL Bully, the Pit Bull terrier, the Dogo Argentino, the Fila Brasileiro and the Japanese Tosa. In addition, under this Act, a dog of any breed or type must be kept under proper control. If it is not, its owner or other person in charge of the dog will be committing an offence. At a local level, there are additional powers available to local authorities to tackle dog control issues, including introducing controls on dog walking. Under the Anti-Social Behaviour, Crime and Policing Act 2014 local authorities can create Public Space Protection Orders (PSPOs). PSPOs can be used by local authorities to restrict the number of dogs walked by any one person, exclude dogs from certain areas or require them to be muzzled or on a lead. Defra published guidance for local authorities on using the powers in this Act for the control and welfare of dogs in 2014. Many local authorities already use this tool to set a maximum number of dogs walked by one person. In addition, some local authorities, such as Surrey County Council, have introduced dog walking codes of conduct which professional dog walkers can sign up to, while others have introduced licensing schemes for professional dog walkers. We believe that local authorities are well placed to understand the specific needs and concerns of their communities and we encourage them to use the powers available to them, such as PSPOs, to prevent dog attacks. Outside of the regulatory regime, several stakeholders have produced useful guidance for professional dog walkers. Most notably, the Canine and Feline Sector Group has published guidance to assist professional dog walkers. The guidance can be found here: General Guidance Documents – CFSG. CFSG’s guidance provides information for commercial dog walkers on key aspects such as group walking and minimising the impact of their activity on other people and animals. For example, dog walkers following the guidance should assess each dog’s suitability for group walking and limit the number of dogs walked at one time to the maximum permitted by their insurance with a suggested limit of four. CFSG’s guidance also provides information on suitable training for dog walkers. This includes City & Guilds accredited training and continual personal development. Defra’s work on this issue While there are clearly existing powers in place at both a local and a national level to tackle dog control issues, as well as additional guidance produced by stakeholders, Defra have been considering what more can be done to promote responsible dog ownership and prevent dog attacks and has been working closely with the police, local authorities and animal welfare organisations in this area. As part of this ongoing work, we will engage with local authorities, the police and animal welfare stakeholders to gather evidence specifically on the use of the existing powers to implement controls on dog walking at a local level. We will also explore any other interventions local authorities and others are employing to reduce dog attacks resulting from individuals walking a large number of dogs or a high total weight of dogs. This will allow us to review the effectiveness of the existing regime and the need for any further national measures. Yours Sincerely, Deputy Director Animal Welfare Division
Mr Travers HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Dear Mr Travers, Woodhatch Place 11 Cockshot Hill Woodhatch Reigate RH2 8EF 20th December 2024 Regulation 28 Report - Action to Prevent Future Deaths – Natasha Johnston The following information is written to provide clarity in response to queries raised by the Coroner relating to the tragic death of Natasha Johnston in January 2023. Currently there is no standardised approach to the regulation of professional dog walkers across England, with a variety of different schemes in place in different areas, or often none at all. The responsibility for providing overall regulation on issues such as the number and weight of dogs being walked sits with the Department for Environment, Food and Rural Affairs (DEFRA), while ‘dog services’ and animal welfare licensing are a Borough and District (or Unitary) Council function, usually as part of its Environmental Health responsibilities. The latter also has the power to serve Community Protection Notices to owners whose dog’s behaviour is having a continuing and detrimental effect on the wellbeing of others, as well as the ability to issue Public Space Protection Orders (PSPOs) in specific geographical areas. It was recognised that in its role as a responsible landowner, Surrey County Council should also take some form of action to promote positive dog walking behaviour in light of this incident, with a particular focus on Professional (paid) Dog Walkers who are often seen with multiple dogs at its countryside sites. For clarity, the guidance applied by Surrey County Council (that has been referred to by the Coroner), most notably its ‘Dog Walking Code of Conduct’, was implemented in response to the incident involving Ms Johnston rather than being in place prior to the event. During Spring/Summer 2023, Council officers discussed this issue with a number of stakeholders before developing an options appraisal, with options that ranged from taking no action through to a formal licensing scheme for users of its Countryside Estate (in this case a license would only apply to Surrey County Council land, because wider licensing is a District and Borough function). While a paid-for licensing scheme was considered, the likely result would be the displacement of the problem onto neighbouring landowners rather than directly addressing the underlying issues. It was considered important to avoid a situation whereby each landowner implements their own licensing scheme, as the public (including professional dog walkers) often do not know whose land they are using, so schemes with different rules, pricing structures etc. would cause significant confusion, frustration and ultimately be ineffective. There was also concern regarding the practicality of the resource required to enforce licensing across Surrey’s significant countryside estate (10,000 acres). While licensing would generate some limited income, it would not be sufficient to pay for the additional resource required to effectively administer the scheme. 1 Licensing would also impact the viability of professional dog walkers themselves, many of whom are micro businesses. A balanced approach was required that did not excessively restrict professional dog walkers’ ability to operate, as there was (and is) an evident need for their services. The Pet Food Manufacturing Association (PFMA) revealed 2.1m people (19% of current dog owners) collected a new pet during the pandemic but as many people have returned to the workplace, professional dog walkers support good canine welfare by exercising the pet when the owner cannot. Code of Conduct Considering the issues above, it was felt the most pragmatic way forward was to take an education- focused approach to improving behaviours, spearheaded by a communications and an engagement campaign for a new “Dog Walking Code of Conduct”. This was designed with the intention of communicating clear and simple messaging for all dog owners (not only professional dog walkers), as it was considered essential to be clear in precise terms about what responsible dog walking entails, so that all visitors with dogs are aware of how to ‘do the right thing’ for other countryside users, livestock and wildlife. Surrey County Council’s Dog Walking Code of Conduct is largely based on the well-established Countryside Code promoted on Gov.uk that establishes responsibilities for visitors to the countryside and those who manage the land. The final version of the code was put together following consultation with partners and other landowners including Thames Basin Heaths Partnership, Battersea Cats and Dogs, The Ministry of Defence (MOD), The National Trust, Horsell Common Preservation Society, Surrey Hills National Landscape and some of Surrey’s Boroughs and Districts. As part of this process officers also sought the counsel of an industry expert who provided independent advice on content and appropriate language for the code. To incentivise professional dog walkers (as the primary target audience) to sign up to the code of conduct and confirm they will support its guidelines, businesses are listed on the Council’s website upon satisfactory provision of their business details and Public Liability Insurance. Businesses who sign up are also provided with car stickers to publicly endorse they are supporters of the code and promote the responsible behaviours within it. The scheme went live in January 2024 and has been extremely effective with 122 professional dog walking companies signing up to date, including some from London and other neighbouring counties who use Surrey County Council’s sites. Many of those who have signed up are hugely supportive and have offered to become ambassadors to help promote responsible dog walking amongst their networks, helping the Council to further its reach. Not only has this process allowed the Council to positively engage with professional dog walking businesses, many of which it did not know existed, but in holding their details on file it means any concerns or complaints can be directly. If not addressed, then consultation with the local District of Borough Dog Warden could take place. The Dog Walking Code of Conduct highlights that walkers should only walk the maximum number of dogs that can be safely controlled, with advice for no more than six. This figure was carefully considered; six dogs is the number referred to in guidance from DEFRA on Public Space Protection Orders (please find extract below) and is the usual maximum used by insurers for professional dog walking cover. The industry expert advised a lower maximum figure could reduce viability and credibility with professional dog walkers and risked undermining the ‘engagement and education’ approach. They added that emphasis should be placed on the number of dogs that can be safely controlled as every 2 dog and walker are different, and so simply stating a fixed maximum without further context would not be sufficient. Surrey County Council officers have hosted multiple outreach events during 2024 to promote the code of conduct, which has included working in partnership with other landowners, such as Guildford Borough Council, to show a collaborative approach and amplify our messaging. Ongoing Commitment While the Code of Conduct is considered to be an effective step in the right direction, it is acknowledged ongoing action will be required. Annual reminders are in place to ensure those who have signed up to the Code of Conduct continue to have valid Public Liability Insurance; and where this is not provided, their details will be removed from the Council’s webpage. As part of its communications programme, the Council sends regular newsletters to professional dog walkers promoting good practices and thanking them for their cooperation. The Code of Conduct will also be promoted on a regular basis through the Council’s ‘Explore Surrey’ social media channels and as part of its approach, ‘ambassadors’ from the professional dog walking community are being used to champion responsible dog walking and spread the word to encourage their peers to sign up. Officers will continue to monitor feedback from the public and professional dog walkers, both formally and anecdotally to review the effectiveness of the Code of Conduct, especially on Surrey County Council’s land. They are also committed to improving their understanding of this work area, with one officer recently completing a professional dog walking qualification so that the Council has a better understanding of their requirements and best practices. It is acknowledged that legislation and guidance around dog walking is an evolving area, but Surrey County Council is committed to continuing to work with its partners to improve dog walking standards and behaviours. The common consensus from discussions with stakeholders in this space (including professional training providers) is that any universal regulation of dog walking needs to be delivered at a national level, likely led by DEFRA. The Council will continue to keep its approach under review, develop its processes as needed, and looks forward to further legislation and clarity on this issue. Yours sincerely, Chief Executive of Surrey County Council 3
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