Dylan Rattray

PFD Report All Responded Ref: 2014-0371
Date of Report 12 August 2014
Coroner Nicola Jones
Coroner Area North West Wales
Response Deadline ✓ from report 7 October 2014
All 1 response received · Deadline: 7 Oct 2014
Response Status
Responses 1 of 1
56-Day Deadline 7 Oct 2014
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) Whilst it is acknowledged that Snowdon is an inherently dangerous terrain which attracts millions of walkers of all abilities every year without incident in most cases, I am concerned that the Snowdonia National Park Authority have chosen not to follow the advice of an organisation such as the Llanberis Mountain Rescue Team which has been given in writing on two occasions detailing how the risk of future deaths and serious injury could be reduced.

(2) The deceased in this Inquest was a sensible , fit , hardworking young man, not a foolhardy risk-taker. He followed what he thought was an established path that would take him down to Glaslyn. Had the Park taken the previous advice of the Llanberis Mountain Rescue team to break up these misleading paths then this death would not have occurred as the deceased would not have attempted to descend the route which he took, which led to his death

(3) It is acknowledged that the Park not only has to consider budgetary constraints but also the difficult and dangerous terrain where improvement works would be required. However, unless robust and permanent measures are taken to ensure that walkers cannot access what they believe to be established paths at the Summit of Snowdon ( thereby providing a mistaken sense of security ) when such paths peter out and leave walkers in perilous positions, then I am satisfied that there will be repeated deaths in these circumstances on Snowdon .
Responses
Snowdonia Park
Response received
View full response
Dear Madam, Your Regulation 28 Report to prevent future deaths unfortunate and tragic death of Dylan Arwee from the inquest the Monitoring Officer for the Authority Rattray has been passed to me aschee to respond fully thereto. and confirm for the sake of clarity that am instructed The Report highlights three main areas of concern individually in due course. Prior to and shall respond to each area understand Snowdonia National so however consider it will be useful for you to therefrom. Park Authority's purposes and any duties arising Snowdonia National Park Authority was established single purpose local authority. It has the by the Environment Act 1995 as a To conserve and enhance the following purposes as defined bythe Act: To promote natural beauty, wildlife and cultural and qualities of opportunities for the understanding and enjoyment of ther specia (National) Park by the public The Act goes on to say that in pursuing National Park shall seek to foster the economic and social Purposes the National Park Authority National Park and shall for that wellbeing of local communities within the whose functions include the potioseco-operate with local authorities and public eodies of the National Park. promotion of economic and social development withinche area theditioole oj Indevahe Envronment Act 1995 the Authority is the local whole of the National The Authority is therefore planning authority for the Park Management Local responsible for the production of applications_ Development Plan and for the determinationr od planning Whilst there are other statutory duties applicable to the to this matter is the legislation appertaining Authority: the main one of relevance (hereinafter referred to as CROW): This to the Countryside and Rights of Act 2000 "elevant authoetyedooare Retivedhis Aumorcceas lenconsibilty under CROV Ast 2e€ route followed by Mr Rattray and access land" can confirm that the entire on in question is onen access land, 3 SVDLAtt+? nf gel arising - into doing statutory heritage; the Park. Plan, Way the day

However this does not extend to responsibility for under CROW include issuing short or personal safety and responsibilities birds stock management The Iserm restrictions and exclusions i,e. for nesting restrictionckoraegeeventiorhei Aamoeitvoalso has responsibility for longer term unexploded munitions fire danger to the public that are man-made egopolution7 stiles and gates for etc There is also the power if the Authority so wishes to accessing and egressing CROW access land;. provide CROW provides the following rights set out in Section 2(1) of ACT: "2 Rights of public in relation to access land {3Any person is entitled by virtue of this Subsection to for the purposes of open-air recreation, enter and remain on any access land (a) he does so without if and so long as (b) he observes the breaking Or damaging any wall; stile or gate, and relatiorts eneelante_gceerGhapeictions in Schedule Z and any other resiictiortemposed in Chapter II. CROW does however specifically restrict copy below the relevant section: any occupiers' liability and in order to assist you / "13 (2) In section 1 of the Occupiers' 'Liability _ than his visitors), after subsection Act 1984 (duty of occupier to persons other "(GA) At any time when the (6) there is inserted Act ?ooomne exeecistableighte elotiorred brcsection 2(1) of the Countryside and Rights of I of that Act; an occupier of Felation to land which is access land for the puposesof Part virtue of this section to PeeSondrores subiect to subsection (6C) beloe)uoduty_ any person in respect of by (a) a risk resulting the existence of any natural stream; ditch or pond whether or not "feature of the landscape, or any river; (b) a risk of that person a natural feature, or Or gafisk %cepatDeproper uiferin9the twhen passing over;, under or through any wall, fence (6B) For the gate or of a stile. {Sto beregerdeoasea oaturbsection (6A) above, any plant; shrub or of whatever as a natural feature of the landscape. origin, (6CJSubsection (6A) does not prevent an occupierarem section in respect of any risk where the duty by virtue of this occupier danger concerned is due to anything done by the (a) with the intention of that risk; Or (b) being reckless as to whether that risk is created: Suming to the management of Snowdon in general there summit of Snowdon which are on are in fact six main paths to the responsibilityoiGonynedch Goencil ea/ Aighoroy does Aithough these are in tacathe fegae main paths on behalf of Chis Authority does in fact manage and promoteetheesa are repaonaDly bexpectecGo vaedd GouncibiHowever, all walkers on these sixmain paehe them tososa adequacteootweake closhogsabd ecorichernselves and we would alsa enourage of pre-route planning before irlotbing and equipment and to haveeundertaken sorcelorge anoresoutcelanfong beoting erougjain Sarervhein mindthe Authortynertaignificanetfnoe visit" phase by providngpteciseottei desceiptioessages and specifically targets thenprene above_ descriptions for all of the main paths referredeto long issuing the fence, hedge , Way from injury- tree, owing creating

The area in question where Mr Rattray fell to his death is not in fact in the ownership of the Authority but rather is owned by the Baron Hill Estate. Neither is the area in question on one of the six main paths that this Authority actively maintains and promotes Having provided you with some background information that hope you will find of use shall now respond in detail to your report: You have raised three matters of concern in your report and shall now deal with each of these separately: Whilst it is acknowledged that Snowdon is an inherently dangerous terrain which attracts millions of walkers of all abilities every year without incident in most cases, am concerned that the Snowdonia National Park Authority have chosen not to follow the advice of an organisation such as the Llanberis Mountain Rescue Team which has been given in writing on two occasions detailing how the risk of future deaths and serious injury could be reduced: Response: Llanberis Mountain Rescue Team first wrote to the Authority on 18th April 2012 detailing its concerns following the death of a walker in poor weather conditions: The walker in question was both experienced and well equipped. It is perhaps unfortunate that no representative from this Authority was called to give evidence at the inquest to Mr Rattray's death as further details could have been provided at that time_ Following said letter a meeting took place with a representative from the Llanberis Mountain Rescue Team on 22nd May 2012. At that meeting the following was agreed:
1) A direction pillar was to be placed between the summit and the back of Hafod Eryri s0 that walkers know the location of the Watkin Path: attached a photograph (marked No. 1) which confirms that this work was subsequently undertaken.
2) Some improvement may be needed to the top of the Watkin Path to provide more definition: However this would necessitate the moving of the definitive right of way:
3) Following on from the above, landscaping the south-east face of the summit to remove where possible braiding and erosion scars_
4) To further discuss the practicality of building some form of low level wall surrounding the area of the summit under the trig point: At that meeting it was made clear that no remedial work on the East Ridge route would be undertaken as although it is not a managed path and not a definitive Right of it is none the less recognised as part of the Snowdon Horseshoe in guidebooks etc: The directional pillars were sited on Snowdon in May 2013. Following discussion with the Mountainsafe Partnership (a partnership set up to foster safety on Snowdon and whose membership consists of the British Mountaineering Council, Mountain Training, North Wales Mountain Rescue Association, Plas y Brenin, North Wales Police, Llanberis Mountain Rescue Team as well as other interested parties) , landowners, the have path Way

Local Access Forum together with additional significant input the Mountain Rescue Team 6 of these directional Pillars were sited Llanberis agreed specific points where evidence on Snowdon at suggests that navigational errors were commonly made_ Although much consultation was undertaken beforehane this in itself was regarded as unnecessary by some "purists' who feel that work should not be signposted in this way and there has been Snowdon the pillars was deliberately defaced. one incident where one of internal meeting and at Following of the same there followed an the that time a decision was made to hold a 12 month review into effectiveness of the of all the directional pillars. Furthermore the change the lines of two public Rights of was initiated process to conjunction with Gwynedd by the Authority in phase_ Highways some time ago and is currently in its consultation {uheeraeberis Mountain Rescue Team were kept informed during this time and further letter was in fact received until 23" Aprii 2014 (dated 20n8 no written following the unfortunate death of Mr Rattray: April 2014) and was contents as the Authority had This letter was unexpected in its Llanberis Mountain implemented an action plan that had been agreed with Rescue This Authority has considerable experience and exertise with regard to visitor safety management principles ina the reality the nature of the terrain and associated activitienc uplands and in prescriptive. does not allow us to be overly attempt to break Up the East Ridge path in particular would be largely futile as it is a well described route which is domain through numerous scrambling widely available in the public would quickly be re-established. and walking guide books and websites and s0 area as well In addition sheep and wild goats also populate this a8 many other areas in Snowdonia and are continuously paths and tracks This is part of the reason Why it is an accepted small principle that paths such as these are not broken upland management up: Between the two incidents referred to in this letter it must be remembered approximately one million people had ascended and descended ee that Although the accidents occurred in a similar area the mountain on foot different with weather conditions and visibility circumstances were markedly This accident poor on the of the 2012 incident: was deemed to have occurred due to navigational error straying from the East Ridge The weccherecondetiongavtigacioine ofor bRaradvertently accident were, by contrast; considered to be perfect; Rattray's have attached a map with this letter (marked A") that shows the taken by Mr Rattray and The final stages of their route likely route detail on the further map (marked is shown in greater B") which is an inset map with aerial oisotogepho_captured in 2013. The hatched area shows the area of lanethat = discussed for possible screening in 2012. was As canbe seen from the likely route and subsequent possible line taken and lit is highly unlikely that this had any impact whatsoever by Mr Rattray accident that was to follow. It is likely that Mr Rattray and in the tragic the East Ridge As previously stated this is a recognised path but linitially followed maintained or promoted by this Authority: Had not one that is could have made their way safeoyito thedNaekic Patnued along the East Ridge have led to their start point of y Pass but rather However, this would not could however have caught the Snowdon to Nant Gwynant: From there Sherpa that would have taken them back to from siting siting Way Team: Any creating day " "Map Map they they Pen they

Pen y Pass. Alternatively could have continued along the ridge over Lliwedd and down to Llyn Llydaw, returning to Pen y Pass to complete the Horsehoe. For whatever reason however, it appears that Mr Rattray led in an attempt to cut across to Llyn Glaslyn, and by doing so left the relative safety of the East Ridge route that then led to such tragic consequences. 2 The deceased in this inquest was a sensible, fit; hardworking young man, not a foolhardy risk taker. He followed what he thought was an established that would take him down to Glaslyn: Had the Park taken the previous advice of the Llanberis Mountain Rescue Team to break up these misleading paths then this death would not occurred as the deceased would not have attempted to descend the route that he took; which led to his death: Response: The Authority takes issue with this point of concern: attach a paper byl and entitled Mountain Rescue Incidents on Snowdon" . This research shows that males were far more likely than females to be involved in incidents and that both Mr Rattray and actually fell into the category most likely to be rescued. As a result the Mountainsafe Partnership worked to develop a smartphone app specifically for this age category because are at a higher risk of involved in incidents. The Authority's Senior Warden for North of the Park actually spoke to both Mr Rattray and as set out on their walk from Pen y The conversation occurred at approximately 2pm. were standing looking at a map of Snowdon by the and Display looking at the main footpaths remembers the conversation as he had not heard many walkers conversing in Welsh that and he enquired where were headed_ informed him that they were going to do Crib Goch but that weren't sure where to leave the PYG track in order to do Crib Goch: 'Bwlch y Moch, by a dry stone and remembers saying next "Are you sure you know what's ahead of One replied that he did, then asked whether were going to the summit and the response from one was "no, it's too and I've been to the summit before then asked "What will you do then return down the PYG from Bwlch Glas?" Both replied that this was what would be doing: Although it was quite late in the to begin such a walk compared to the many hundreds who had traversed the mountain earlien assessed that there was plenty of daylight hours left for the planned route. attach a further map (marked "Map D") which shows the planned route as explained to= and the actual route subsequently followed. On the question of equipment noted that one was wearing trainers and that both had small rucksacks. It later transpired that neither had a guide book, map or compass: The possession of such simple equipment would no doubt have informed them that there was in fact no suitable route from the East Ridge to Llyn Glaslyn: Having talked to a number of experienced walkers all have expressed an opinion that it should have been clear; particularly given the extremely favourable weather conditions on the and the obvious nature of the terrain, that to attempt what they did was in fact what could only be categorised as an extreme risk. This is perhaps borne out by the testimony of at the Inquest who was following Mr Rattray, asked Mr Rattray on no less than three occasions for him to turn back they path have they being the they - Pass: They _ Pay day - they - They they replied wall" you?" they busy, they day - day

The third and request was only made about one minute before Mr Unfortunately Mr Rattray chose not to acquiesce 010is iriere b Rattray's fall. request. Ars eaplained previously Whether or not work had been undertaken to the on Map B was irrelevant to the cause of the accident hatched area had successfully as it appears that Mr Rattray and the area in question before havigated the East Ridge along the established path past to Llyn Glaslyn. As sthen deciding to veer off the East Ridge to attemptao get attempt and previously explained there is no recognised route for scptan have ineossession of such simple tools as a compass and map would ensured that were fully appraised of the risk that were about to take
3. It is acknowledged that the not only has to consider but also the difficult and dangerous terrain where budgetary constraints required: However; unless robust and improvement works would be that walkers cannot access permanent measures are taken to ensure Summit of Snowdon what believe to be established paths at the such paths peter (thereby providing mistaken sense of security) when out and leave walkers in perilous positions, then / am that there will be repeated deaths in these circumstances satisfied on Snowdon. Response: Thecpoint should be made at the outset that this is not about attach for your information Visitor Monitoring Figures for budgetary constraints.
2013.This shows the number of visitors to Snowdon Snowdonia National Park for Park As such the Authority has chosen dwarfs all other mountains in the Rights of In to try and direct visitors along the prescribed doing so visitors can expect to encounter a challenging day but along paths that are actively maintained. The Authority Safety in Countryside and complies fully with the Visitor the principles an extract of the Group's publication including therefrom governing such activities are also attached to this letter: As can bei it is one of principles that: seen "Where risk arises natural features, such as cliffs, rivers, streams, trees and rocks; it is not desirable to restrict access lakes; diminish the amenity or take other measures that simply from fear that an accident may result in prosecution . People should be allowed to participate in leisure pursuits sueh and water sports that are potentially hazardous as bungee jumping The case of Tomlinson V Congleton Borough Council Brereton is mentioned where Lord Hoffman's Heath Park "it will be extremely rare for opinion was that: ian occupier of land to be under a duty to prevent people taking risks which are inherent in the activitiesehan undertake upon the land i people wantfo alimbienotratainey gceeanchoidingoc or dive in ponds or that is their affair. Of go hang-gliding or swim reasons wish to prohibit such activities. course the landowner may for his own inconvenience He may think that are a danger or to himself or others: Or he may take a paternalist view and people not to undertake risky activities on his land: prefer Chiohowever is not an option on Snowdon as it is open access land CROW but this is perhaps reflected in the fact that CROWC as defined by liability for natural features. has intentionally limited final being they . they Park they Way: the Group the from falling Country from they - lakes, they

The above does not of course mean that the Authority does not take visitor safety seriously but the reality is that all mountains have false paths and walkers should be aware Referring once more to the report entitled Mountain Rescue Incidents on Snowdon" it can be seen that overall the accident rate averaged over the period was 69 hours for every million hours spent on the mountain but that if uninjured callouts are excluded then this falls to 30 for every million hours on the mountain_ This is in fact a lower rate than for mountaineering in general (40) , horse (100) and football (1300). In fact it is comparative to the sport of fishing (30). Such an accident rate is perhaps a testimony to the hard work put in by the staff of this Authority in maintaining the six main routes, by the Park Wardens in advising members of the public and by the significant amount of information that the Authority provides freely via its website_ This does not of course mean that the Authority is complacent as to the future. The challenges of Snowdon are in many ways from the sheer number of visitors, to the challenging conditions that the Authority's workforce face in maintaining the maintained routes in suitable condition. The provision of signage and re-routing the Watkin Path will hopefully ensure walkers are provided with more information and clearer route. What is almost certain however is that these measures would not have affected the outcome of this unfortunate accident_ trust that the above adequately explains the Authority's position in this unfortunate incident: If you require any further clarification please do not hesitate to contact me_ Alternatively, if you wish to see the area for yourself | can confirm that one of our Wardens for Snowdon would be more than happy to accompany you on any fact finding visit:
Report Sections
Investigation and Inquest
On 22 April 2014 I commenced an investigation into the death of Dylan Arwel Rattray aged 21 years. The investigation concluded at the end of the inquest on 30 July 2014. The conclusion of the inquest was that the medical cause of death was 1a Multiple Injuries 1b. Consistent with a fall from a height
Circumstances of the Death
The deceased was a fit and healthy young man who walked to the summit of Snowdon along the challenging route of Crib Goch with his friend who was of similar fitness. Neither were particularly experienced mountaineers. Their footwear was unsuitable to areas off the paths. It was their plan to stick to the paths on Snowdon they did not carry maps or guide books and were therefore heavily reliant upon the paths. The pair decided to descend from the summit using what appeared to be an established path heading down towards Glaslyn. This covers an area known as Clogwyn Y Garnedd. After walking for 30 minutes the path petered out and the pair found themselves on loose scree. The deceased decided to press on as the pair realised that it was impossible to return the way they had descended due to the terrain. Moments later the deceased fell some 200 metres sustaining fatal injuries. The surviving friend was left in a perilous position on the mountain and was rescued thanks to the joint efforts of the RAF search and Rescue Helicopter and Llanberis Mountain Rescue Team whose lives were also at risk due to the terrain. The deceased was recovered by the SAR helicopter but prior to the arrival of the helicopter some nearby walkers ( medical students) left the PYG track to attempt to assist the deceased. Their lives were also endangered by this act. The friend of the deceased gave evidence that the pair would never have taken the descending route had they known that this was not a continuous and established path. At Inquest Mr the Chairman of Llanberis Mountain Rescue Team gave evidence that there have been multiple casualties and rescues on Snowdon due to walkers using paths which appear to be established and continuous paths down /up the mountain but eventually peter out leaving walkers in life threatening situations. In April 2012 a walker died in similar circumstances to the deceased. He stated that on three occasions the LMRT have written to the Park Authority and have requested that the Park Authority give serious consideration to breaking up these paths to prevent further serious injury and loss to life, not just to walkers but also to rescuers. He stated that LMRT did not feel sign posting alone would provide the necessary safeguards. in particular requested minor changes to the definitive lines near the Summit of Snowdon in particular at The Watkin Path and The Cwellyn , together with work to diminish paths which appear established but peter out. The Snowdonia national Park did not follow the advice but invested in signposting. On the day of the Inquest another walker fell to his death in the same location of the deceased

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) Whilst it is acknowledged that Snowdon is an inherently dangerous terrain which attracts millions of walkers of all abilities every year without incident in most cases, I am concerned that the Snowdonia National Park Authority have chosen not to follow the advice of an organisation such as the Llanberis Mountain Rescue Team which has been given in writing on two occasions detailing how the risk of future deaths and serious injury could be reduced.

(2) The deceased in this Inquest was a sensible , fit , hardworking young man, not a foolhardy risk-taker. He followed what he thought was an established path that would take him down to Glaslyn. Had the Park taken the previous advice of the Llanberis Mountain Rescue team to break up these misleading paths then this death would not have occurred as the deceased would not have attempted to descend the route which he took, which led to his death

(3) It is acknowledged that the Park not only has to consider budgetary constraints but also the difficult and dangerous terrain where improvement works would be required. However, unless robust and permanent measures are taken to ensure that walkers cannot access what they believe to be established paths at the Summit of Snowdon ( thereby providing a mistaken sense of security ) when such paths peter out and leave walkers in perilous positions, then I am satisfied that there will be repeated deaths in these circumstances on Snowdon .
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.