_ (a) The average space between the uprights on the parapet on the aqueduct is 195mm whilst the current industry standard is 11Omm as a result of which there exists a risk that a person might be able to pass between them_ This is a particular risk for children using the aqueduct but it is also a significant risk for young persons or adults being of sufficient width for them to pass through in circumstances whereby it was their intention to gain access to the non-pedestrian side of the parapet for a purpose which would not be considered the intended use of the structure In my opinion, the use of signage alone, warning users of the potential risk, does not adequately mitigate the risk of a person passing through the uprights and falling from the aqueduct. Coroner Olficc, County Hall, Wynnstay Road, Ruthin, LLIS AIN Tel 01824 708047 Fa 01824 708048

(b) Evidence provided by an expert instructed by the Canal and River Trust (CRT) indicated that it was his belief that the upright became detached as a result of a lifting action which dis-engaged the nib on the bottom of the upright from the socket on the outside of the parapet: The evidence provided to the inquest by engineers from CRT advised that their inspection procedures provided for an Annual Inspection which included testing for the extent of embedment by a pushlpullllift test; however in my opinion the subjective elements of this test this would permit inconsistencies in the information which it provides Furthermore, exact measurements of the degree of embedment of uprights would only routinely be established in the course of a Principal Inspection which takes place twenty years and as a result it is difficult for there to be an accuratelregular assessment of the rates of possible deterioration and hence the true extent of embedment In my opinion, the testing processes currently adopted (in regard to the matters detailed above) are inadequate to ensure that the uprights are properly engaged at all times.