Laura Smallwood
PFD Report
All Responded
Ref: 2022-0109
All 1 response received
· Deadline: 21 Jun 2022
Sent To
Response Status
Responses
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56-Day Deadline
21 Jun 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
Until recently, there had been a lack of involvement by the Oss committees with the Local Safety Advisory Group (LSAG.) This had compromised planning and risk management for the event. That situation has improved significantly with the appointment of an external liaison officer by the Oss committees. Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an 'Event Organiser' for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety. I heard in evidence that the current legislative framework does not provide the police or Information Classification: CONTROLLED any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from:
- Inspector ;
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- Inspector ;
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Responses
Response received
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Dear Mr Cox, Re: Regulation 28 Prevention of Future Deaths letter Re: Laura Amy Smallwood I am grateful to you for bringing to my attention the circumstances surrounding the death of Laura Smallwood. I was saddened to hear how what should have been an enjoyable day turned out so tragically. I would ask that you please convey my condolences to Laura’s family and friends. When you wrote to Minister Kit Malthouse on 7 April 2022 you raised two issues:
- Whether there is adequate legislative authority currently to ensure safety at public gatherings where there is no Event Organiser to liaise with an LSAG or other external agencies;
- Whether additional powers need to be given to the police or others to grant or refuse permission for a particular event to take place in the absence of the appointment of an Event Organiser with meaningful engagement with an LSAG so that public safety considerations are properly addressed. I appreciate you extending the deadline for me to respond thereby allowing me to consult colleagues across Government who have responsibility for national policy around public events and health and safety.
We want public events to be safe for those who take part or spectate, and for the vast majority of the time that is what we see. That is often thanks to the people who are willing to take on responsibility for aspects of the organisation and liaise with the local authorities to draw on their expertise in keeping people safe. I was pleased to read in your report that some element of that now happens with the Oss committee. As you indicate, however, the Safety Advisory Groups do not have a statutory basis. This does mean the SAG has no limitations as to what events it considers, should it so desire. It can consider events regardless of venue public or private; free to attend or ticketed; traditional or novel events; regular or occasional; or voluntary or charitable. It does also mean that attendance or engagement with the Safety Advisory Groups is voluntary and there is no legal requirement to appoint an organiser or to engage with the local authority or law enforcement. The Cabinet Office’s Emergency Planning College (EPC) recognises this possibility and notes that it may be challenging. It is the Government’s view that where there is no organiser, or an event organiser declines to engage in safety processes, it should not prevent the Safety Advisory Group taking reasonable steps to review the safety arrangements of an event. The EPC guidance, The UK Good Practice Guide to Working in Safety Advisory Groups, states: “It is important to consider why an organiser is unwilling or unable to engage. It will be important to demonstrate that a SAG is well intentioned and focused on working with organisers, by considering the safety aspects of their event. The SAG should not be considered as a threatening environment as the safety of all involved in an event should be mutually beneficial. The SAG should not make unreasonable or unfair demands on the organiser and the options highlighted in section 3.8 under ‘smarter working’ should be considered. These include technological solutions such as video/teleconferencing. The SAG should also guard against placing disproportionate demands on organisers of what are obviously very low-risk events. Wherever possible SAGs should still seek to assess the safety arrangements of an event, despite such a lack of participation by an organiser. It should also then address any issues raised by the most appropriate means. It will be particularly important to ensure that accurate and appropriate records of representations and correspondence are maintained in these situations. In any case, the SAG chair should coordinate its members’ desires and attempts to communicate with the organiser, ensuring that attempts are recorded and properly documented.”1 Those who attend Safety Advisory Groups do have a range of powers that may be applicable. For example, the local authority will have licensing powers and the Health and Safety at Work Act 1974 would apply where the planning, organising, or running of an event is a work activity. In extremis, the police 1 Emergency Planning College, The UK Good Practice Guide to Working In Safety Advisory Groups, Part 2 Supporting Appendices (The Emergency Planning College: 2019), 12 Microsoft Word - The UK GPG to WSAG Part 2 (epcresilience.com)
could act to prevent a breach of the peace. The EPC’s guidance sets out the powers which may be relevant in more detail.2 The Government believes there is great value to our national life in communities being able to celebrate their local traditions, bringing people together to take pride in their area, and strengthening community spirit. For that reason, we have taken the view that it is better to support and encourage sensible planning and preparation, rather than to mandate every element of it through legislation. The latest public guidance from the Cabinet Office (Organising a voluntary event: a 'can do' guide - GOV.UK (www.gov.uk) )is intended to help people planning voluntary events, with advice on the steps that organisers should take. To amend the law in this area sadly would not necessarily prevent the – mercifully rare – occasions when something goes tragically wrong as it did in this case. Consequently, the government believes that we should continue to encourage those wishing to organise events to engage sensibly with local experts to keep people safe.
- Whether there is adequate legislative authority currently to ensure safety at public gatherings where there is no Event Organiser to liaise with an LSAG or other external agencies;
- Whether additional powers need to be given to the police or others to grant or refuse permission for a particular event to take place in the absence of the appointment of an Event Organiser with meaningful engagement with an LSAG so that public safety considerations are properly addressed. I appreciate you extending the deadline for me to respond thereby allowing me to consult colleagues across Government who have responsibility for national policy around public events and health and safety.
We want public events to be safe for those who take part or spectate, and for the vast majority of the time that is what we see. That is often thanks to the people who are willing to take on responsibility for aspects of the organisation and liaise with the local authorities to draw on their expertise in keeping people safe. I was pleased to read in your report that some element of that now happens with the Oss committee. As you indicate, however, the Safety Advisory Groups do not have a statutory basis. This does mean the SAG has no limitations as to what events it considers, should it so desire. It can consider events regardless of venue public or private; free to attend or ticketed; traditional or novel events; regular or occasional; or voluntary or charitable. It does also mean that attendance or engagement with the Safety Advisory Groups is voluntary and there is no legal requirement to appoint an organiser or to engage with the local authority or law enforcement. The Cabinet Office’s Emergency Planning College (EPC) recognises this possibility and notes that it may be challenging. It is the Government’s view that where there is no organiser, or an event organiser declines to engage in safety processes, it should not prevent the Safety Advisory Group taking reasonable steps to review the safety arrangements of an event. The EPC guidance, The UK Good Practice Guide to Working in Safety Advisory Groups, states: “It is important to consider why an organiser is unwilling or unable to engage. It will be important to demonstrate that a SAG is well intentioned and focused on working with organisers, by considering the safety aspects of their event. The SAG should not be considered as a threatening environment as the safety of all involved in an event should be mutually beneficial. The SAG should not make unreasonable or unfair demands on the organiser and the options highlighted in section 3.8 under ‘smarter working’ should be considered. These include technological solutions such as video/teleconferencing. The SAG should also guard against placing disproportionate demands on organisers of what are obviously very low-risk events. Wherever possible SAGs should still seek to assess the safety arrangements of an event, despite such a lack of participation by an organiser. It should also then address any issues raised by the most appropriate means. It will be particularly important to ensure that accurate and appropriate records of representations and correspondence are maintained in these situations. In any case, the SAG chair should coordinate its members’ desires and attempts to communicate with the organiser, ensuring that attempts are recorded and properly documented.”1 Those who attend Safety Advisory Groups do have a range of powers that may be applicable. For example, the local authority will have licensing powers and the Health and Safety at Work Act 1974 would apply where the planning, organising, or running of an event is a work activity. In extremis, the police 1 Emergency Planning College, The UK Good Practice Guide to Working In Safety Advisory Groups, Part 2 Supporting Appendices (The Emergency Planning College: 2019), 12 Microsoft Word - The UK GPG to WSAG Part 2 (epcresilience.com)
could act to prevent a breach of the peace. The EPC’s guidance sets out the powers which may be relevant in more detail.2 The Government believes there is great value to our national life in communities being able to celebrate their local traditions, bringing people together to take pride in their area, and strengthening community spirit. For that reason, we have taken the view that it is better to support and encourage sensible planning and preparation, rather than to mandate every element of it through legislation. The latest public guidance from the Cabinet Office (Organising a voluntary event: a 'can do' guide - GOV.UK (www.gov.uk) )is intended to help people planning voluntary events, with advice on the steps that organisers should take. To amend the law in this area sadly would not necessarily prevent the – mercifully rare – occasions when something goes tragically wrong as it did in this case. Consequently, the government believes that we should continue to encourage those wishing to organise events to engage sensibly with local experts to keep people safe.
Action Should Be Taken
The matters I bring to your attention are:
- Whether there is adequate legislative authority currently to ensure public safety at gatherings where there is no Event Organiser to liaise with an LSAG or other external agencies?
- Whether additional powers need to be given to the police or others to grant or refuse permission for a particular event to take place in the absence of the appointment of an Event Organiser with meaningful engagement with an LSAG so that public safety considerations are properly addressed?
- Whether there is adequate legislative authority currently to ensure public safety at gatherings where there is no Event Organiser to liaise with an LSAG or other external agencies?
- Whether additional powers need to be given to the police or others to grant or refuse permission for a particular event to take place in the absence of the appointment of an Event Organiser with meaningful engagement with an LSAG so that public safety considerations are properly addressed?
Report Sections
Investigation and Inquest
On 7.4.22, I concluded an inquest into the death of Laura Amy Smallwood, a 34-year-old paediatric nurse, who died in University Hospital Plymouth on 4.5.19. The medical cause of death was recorded as: 1a) Brainstem infarction; 1b)Bilateral vertebral artery dissection 1c)
Circumstances of the Death
May Day is celebrated annually in Pad stow with what is called the Obby Oss festival. An Oss is a hooped structure resembling a hobby horse that weighs about 50lbs and is processed through the streets over the course of the day. There are two separate 'Osses.' The day is extremely popular and can attract up to 20,000 visitors to the town. On 1 May 2019, Laura was unintentionally struck to the back of her neck by an Oss when the carrier lost his balance and fell over. She deteriorated acutely at the scene and suffered a respiratory arrest. She was taken by air ambulance to hospital but died from her injuries.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.