Christopher Townsend

PFD Report All Responded Ref: 2024-0283
Date of Report 5 April 2024
Coroner James Puzey
Coroner Area Worcestershire
Response Deadline est. 26 July 2024
All 1 response received · Deadline: 26 Jul 2024
Sent To
  • Auto Cycle Union
Response Status
Responses 1 of 1
56-Day Deadline 26 Jul 2024
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
(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 requirement for ACU events held on an international/European permit (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 Guidance Note 5 (November 2020), especially paragraph 7 thereof. 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.

(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.
Responses
Auto Cycle Union
5 Apr 2024
Response received
View full response
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 requirement for ACU events held on an international/European permit (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 Guidance Note 5 (November 2020), especially paragraph 7 thereof. 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. (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 In evidence, explained that safety planning was required for all ACU permitted 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
Report Sections
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.
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
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.