Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0065, written 5 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2025 |
|---|---|
| Reference | 2025-0065 |
| Deceased | Simon Harding |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Road (Highways 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Transport, 2. Secretary of State for Culture, Media and Sport of the United Kingdom, 1 CORONER I am Samantha Marsh, Senior Coroner for Somerset 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 16th September 2022, I commenced an investigation into the death of Simon Timothy Harding (“Simon”), aged 41. The investigation concluded at the end of the inquest on 22nd January 2025. The conclusion of the inquest was Accidental Death, with the medical cause of death being recorded as: Ia) Diffuse Axonal Injury, Subarachnoid Haemorrhage, Intra-Ventricular Haemorrhage, and Skull Fractures. Ib) Fall from Motor Cross Bike I recorded in box 3 of the Record of Inquest that: “On the 10th September 2022 Simon Timothy HARDING, aged 41, was riding his Yamaha YZ250 moto-cross motorcycle around the Granfield Moto-Cross Track in Middlezoy when he has entered the Table Top jump at the end of the course. He has failed to successfully negotiate this jump as he had done multiple times throughout the day. Simon has become separated from his bike mid-air and landed on the ground with his bike landing directly on his head. He sustained catastrophic and unsurvivable head injuries as a result and, despite being air lifted to Southmead Hospital, where he underwent neuroprotective investigation and viable treatment, his injuries were ultimately unsurvivable and he died on the Twelfth of September 2022. In absence of any other external factors the accident appears to have been due to a misjudgement by a very experienced rider”. 1 4 CIRCUMSTANCES OF THE DEATH Simon was an experienced moto-cross rider, having ridden most weekends for recreation for many years (in excess of 20 years). On the 10th September 2022 Simon had travelled with members of his family to the Granfield Westonzoyland Moto-Cross Track in Langport Road, Middlezoy, Bridgwater (“the Track”). Simon had ridden on the Track many times before. On arrival those riding (which included Simon) had to fill in paperwork, sign a disclaimer and pay the fee to enable them to ride the Track. The Track was open to the public and so Simon accessed the Track with various other members of the public that day. There was a ‘kids/junior’ track for younger less experienced riders, but all other riders were on the main track. Simon rode, on a self-regulated basis; riding for give-or-take ten minutes and then coming off for a break of up to half an hour, before rejoining. All other riders at the Track appeared to be partaking on a similar self-regulated basis, although the periods of their ride versus rest were not ascertained and so it was open to riders to ride for longer should they wish. Simon had completed numerous laps of the Track on that day without incident. The entire track included a final ramp/jump called ‘The Table Top’. Riders accelerate up a ramp (made of earth), complete a flat section at the top before exiting via the downward ramp at the other end. In practice, due to speed, riders would project off of the flat elevated section and propel through the air before landing and rejoining the downward ramp. Simon commenced his final circuit of the Track just before 13:00. There was nothing out of the ordinary on his final approach and acceleration onto the Table Top but it was visible to witnesses that almost immediately upon projecting into the air, Simon was in difficulty. He became separate from his bike mid-air and was therefore unable to push his bike away from him as he fell. He landed back on the track on his head, with his bike (a Yamaha YZ250) landing directly on his head. The force of the crush impact generated by the bike broke his helmet. Simon sustained catastrophic head injuries as a result of the accident and was airlifted to Southmead Hospital in Bristol where the true extent of his head injuries were revealed. They were unsurviable and Simon died two days later. 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 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. – 2 (a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics of other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information. (b) There did not appear to be any kind of safety briefing for the riders before using the Track. (c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike. (d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track. (e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived. Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity. It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 3 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd April 2025, 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) (ii) (iii) Simon’s family; The owners and operators of the Granfield Track Somerset Council I have also sent it to the following, who may find it useful or of interest. (iv) The Auto-Cycle Union Ltd (“ACU”) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 5th February 2025 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.
Minister for Sport, Media, Civil Society and Youth Department for Culture, Media and Sport 1st Floor 100 Parliament Street London SW1A 2BQ E: www.gov.uk/dcms 2 April 2025 Your Ref: Our Ref: Ms Samantha Marsh Senior Coroner for Somerset Dear Ms Marsh, Thank you for your correspondence of 5 February, to the Secretary of State for Culture, Media and Sport, the Future Deaths Report, concerning Mr Simon Timothy Harding. I am responding as the Minister for Sport, Media, Civil Society and Youth. , enclosing a copy of the Regulation 28 Prevention of I was sincerely sorry to hear about this tragic incident and my deepest sympathies are with the family and friends of Mr Harding. The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will always be risks associated with participating in motor sports, but it is important that robust measures are in place to reduce the risk of major injuries and health issues. It is the responsibility of individual motor sport event organisers to ensure that they protect the safety and wellbeing of their participants. Sport England, our arm’s-length body for grassroots sport, recognises motocross as a sporting discipline of motor cycling and recognises the Auto Cycle Union (ACU) as its national governing body. Sport England considers all motor cycling sports to present risk to competitors, so will only fund motor cycling organisations affiliated to the ACU. The ACU is able to authorise motocross events and venues such as practice tracks under the Motor Vehicles (Off Road Events) Regulations 1995, but this is not a requirement for practice tracks to operate. We understand from the ACU that this tragic incident took place at a private motocross practice facility at a venue not known to the ACU, and the event was not regulated or permitted by them or any other authorising body. I believe you have contacted the ACU in regards to what track safety standards would be expected had this event been authorised by them. I understand that for events linked to the ACU, a risk assessment document must be completed and the track/circuit must comply with the Track Safety Standards document for Motocross. In addition, the event would need a valid ACU Course Licence which would be issued after an inspection by an ACU Track Inspector for compliance with the ACU Track Safety rules. The event would be run in accordance with the ACU Motocross Standing Regulations, which include minimum medical requirements and would require trained and licensed ACU officials and marshals to run the event. Regardless of whether an event is regulated or authorised by a governing body, it is important to be clear that health and safety laws apply. The Health and Safety Executive (HSE) applies workplace health and safety law in relation to those with duties under the Health and Safety at Work Act 1974 (HSWA) and other associated workplace regulations. The activity that Mr Harding was participating in would be arranged as a business activity and those responsible for the event and venue would have duties under HSWA and workplace regulations. HSE has produced the guidance document HSG112 “Managing health and safety at motorsport events: A guide for motorsport event organisers”. This guidance is primarily aimed at motorsport event organisers and venue owners to assist in their understanding of compliance to their duties under the HSWA. It may also be a useful reference for those who operate business activities where members of the public attend to experience motorsport style activities, commonly known as “track days”. HSE confirms that health and safety law as currently drafted does not place a requirement for trained first aid staff in relation to participants and spectators, though guidance does strongly recommend that such persons are included in any first aid needs assessment (HSG112, paragraph 159). In conclusion, I share your concerns about the safety of motocross events held on private facilities without the involvement of an expert organisation such as the governing body. As a result of this tragic case, officials from the Department for Culture, Media and Sport will look to work with Sport England, HSE, the ACU and other relevant stakeholders including the Department for Transport to assess what actions may be possible to improve track safety further and help prevent future deaths at motocross activities. We will set out next steps as appropriate as soon as we are able to. Thank you again for your important contribution to this issue. Yours sincerely, Minister for Sport, Media, Civil Society and Youth
Subject: RE: Simon Timothy Harding (ref: 07/02/2025, 14:56:54 Sent: From: To: Somerset ) Good afternoon, Thank you for your email. Our officials have advised that the matters of concerns raised would not be appropriate for DfT to respond but is for DCMS, as the bike crash happened on a racetrack and not on the public highway. I can see that you have already sent a copy of the report to DCMS. Kind regards, | Correspondence Allocations Manager, , Department for Transport From: Somerset Sent: 05 February 2025 10:42 To: POCorrespondence Subject: Simon Timothy Harding (ref: Dear Ms Alexander, Secretary of State for Transport, Our case reference: 14400408 Please see attached Regulation 28 Report to Prevent Future Deaths. Kind regards, For and on behalf of The Office of the Senior Coroner for Somerset Somerset Dear , Secretary of State for Transport, Our case reference: Please see attached Regulation 28 Report to Prevent Future Deaths. Kind regards, For and on behalf of The Office of the Senior Coroner for Somerset Somerset Coroners Service Offices and Courts at Old Municipal Buildings Corporation Street Taunton Somerset TA1 4AQ Tel: 01823 359271 Contact us about this case NOTE: Please do not edit the subject line when replying to this email. iCW legalsomerset _______________________________________________________________________________________ ___ This email has originated from external sources and has been scanned by DfT’s email scanning service. _______________________________________________________________________________________ ___
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