David Worthington

PFD Report All Responded Ref: 2018-0257
Date of Report 29 August 2018
Coroner Christopher Dorries
Response Deadline ✓ from report 24 October 2018
All 1 response received · Deadline: 24 Oct 2018
Response Status
Responses 1 of 1
56-Day Deadline 24 Oct 2018
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 Concern
_ In the circumstances it is my statutory to report to you: a) The risk assessment prior to the event had not identified the particular location as a risk In many ways this is understandable, Plank Gate is a minor junction. b) However, more detailed consideration might be thought to show a different picture_ There were 2900 cyclists progressing swiftly down a lengthy descent into a blind bend. The organisers efforts in putting a 'slow' sign part way down the descent were, on the evidence of witnesses, largely ignored. c) Plank Gate is the entrance to a moderately school and hacking centre. Sunday morning is a common time for such activities_ d) Whilst the risk of a vehicle leaving Plank Gate across the path of fast-moving cyclists might reasonably have been considered Iow, other element of a risk assessment is the likelihood of injury if such an event did occur: The risk of harm, as identified by this collision was extremely high. e) It is accepted that the route of this prestigious and worthwhile event changes regularly so that Finkle Street lane is unlikely to be used again. Nonetheless, in my respectful submission there is room for a review of the risk assessment methods used for future events. As this incident shows, unlikely events can and do occur and where the risk of harm is high proper consideration is essential.
Responses
Humanrace
19 Oct 2018
Response received
View full response
Dear Re: Mr. David Worthington (deceased) Regulation 28 Response Thank you for your feedback and the advice set out within your Regulation 28: 'Report to Prevent Future Deaths' , dated the 29th August 2018_ As you heard during the inquest into the tragic death of Mr. Worthington ("the Inquest') , Sportive events require extensive planning: A primary focus for Human Race during the planning of all our events is always the health and safety of the participants, volunteers, staff and the general public As you made clear from your personal experience, you are aware that Finkle Street Lane is; a carriageway with traffic travelling in either direction, the subject of a speed limit of 60 mph and has a tarmacadam surface. Plank Gate is an un-adopted carriageway just off Finkle Street Lane, which leads to an equestrian centre There were no signs or street furniture in place by the Highways Authority to advise users of Finkle Street Lane that there was a junction to an un-adopted carriageway around the bend, or to suggest to road users that it was in any unsuitable for cyclists to pass Prior to the event, as you heard, a formal risk assessment was performed of the route in general and of the junctions which the Sportive would pass through (at which riders would be required to make a decision by performing a manoeuvre): In addition, prior to the event (the day before and on the morning of the event) the route was both driven and ridden by the route management team, along with a motorcycle marshal, meaning that further dynamic risk assessments were performed across the route by a number of individuals, likely with different subjective views of risk: As part of our approach to the management of the Sportive in question, we employed motorcycle marshals ("MOTOs') from a supplier that works across all of our events. The MOTOs are often, but not exclusively, ex members ofthe police service: As part ofthe verbal and written briefing which receive prior to an event, they are all instructed to raise any issues which identify either before or during an event with event RECFT Sir , good put along they they

control (all are in radio and telephone contact with the event control room) On the day of the event in question there were 16 MOTOs on The route which the event was to take was presented and formulated at Safety Advisory Group meetings with the Local Authority and the Police in attendance. During those meetings, no concerns were raised about the junction between Finkle Street Lane and Plank Gate. Prior to the event, the Event Director drove the route with colleagues in the Route Team and decided to in position a further 'slow' sign part way down Finkle Street Lane to help remind road users (including motorists) to slow as they travelled down the downhill section of the road. On the of the event, prior to the start, one of the MOTOs employed drove the route and did not make any suggested alterations to the route: As we have already said, there were a total of 16 MOTOs on during the event; who all performed dynamic risk assessments as they travelled around it throughout the event: You will recall the evidence of the MOTO who gave evidence during the Inquest; that he would not have raised issue with the junction between the Finkle Street Lane and Plank Gate, even with the benefit of hindsight As the event moves each year, the probability that we would be hosting an event which travels along Finkle Street Lane again, is low. However, should that ever happen, given Mr. Worthington's tragic death, we would now be on notice of the particular issues concerning the junction between Finkle Street Lane and Plank Gate (as identified by the Police Officer who gave evidence at the Inquest), which had not previously been raised with us by the relevant Local Authority, the Highways Agency or the Police. To that end, we would pay particular attention to the entrance to Plank Gate at Safety Advisory Group meetings and any potential control measures which could be in place to mitigate against the risk which you have identified would be given further consideration_ In your regulation 28 report; you respectfully submit that 'there is room for a review of the risk assessment methods used for future events"_ As with any responsible business, we have attempted to learn from this tragic accident: The very happening ofit has re-enforced the need for us to consider all potential eventualities when planning/risk assessing a route with the various stakeholders involved, however, it remains impossible to conceive or plan for all potential eventualities outwith those which are reasonably foreseeable, specifically in circumstances where the Highways Agency responsible for the road in question has not raised issue with particular area, asked for the section of road to be closed, or installed any signs or street furniture, which might trigger a concern in the minds of those planning the route: To that end, we respectfully maintain that it was not reasonably foreseeable, when planning and risk assessing the route for the event; that a coach would be performing a three-point turn into Plank Gate having travelled down a road which was clearly marked with 'low bridge' signs. In support of that contention, you will recall that it was confirmed during the duty: put long day duty put

witness evidence which was read out at the Inquest that it was very rare for a coach to proceed down Finkle Street Lane_ Whilst we respectfully maintain that the events which tragically unfolded were not reasonably foreseeable, either prior to or during the event, we of course undertake to do our absolute best to ensure that, as far as reasonably practicable, we consider all potential eventualities when assessing routes and planning future events. As a company we analyse our events during their planning phase, during their delivery, and after the event to evaluate what; if anything, can be improved upon and learnt for future events To that end; Human Race will of course take on board your comments when planning and risk assessing future events.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you; the named organisation have the power to take such action.
Report Sections
Investigation and Inquest
In May 2017 | commenced an investigation into the death of Mr David Worthington. The investigation concluded following an inquest in JulylAugust 2018 where the narrative conclusion set out that: Mr Worthington suffered fatal injuries whilst taking part in a Cycling Sportif event on the 30th April 2017. He had travelled down the lengthy descent of Finkle Street Lane at Wortley and, like other riders, was most probably travelling at about 30-35 mph: As he rounded a limited visibility bend he was confronted by a 12 metre coach turning right out of Plank Gate The visibility was limited for both cyclist and coach driver: Mr Worthington braked hard and attempted to miss the vehicle but was unable to do sO.
Circumstances of the Death
See narrative conclusion above and the detailed findings of the inquest previously supplied: A copy of my decision document is attached for those who have not previously had sight of it; being and
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.