Ruwaida Adan

PFD Report All Responded Ref: 2022-0336
Date of Report 22 October 2022
Coroner Leanne Woods
Coroner Area East London
Response Deadline ✓ from report 19 December 2022
All 1 response received · Deadline: 19 Dec 2022
Response Status
Responses 1 of 1
56-Day Deadline 19 Dec 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
Whilst I received evidence that the system at Capital Karts has changed so that a person wearing a headscarf is now required to remove the item in reception and that must be witnessed, I continue to have a concern that there is a risk of future deaths.

1. I am concerned about the current system's apparent reliance on checks at the reception area, particularly when it comes to long hair, which obviously cannot be removed and so may be untucked from a suit or come out of a suit before karting commences.
2. A current race director, who was a race director on 6 August 2021, stated it was a regular occurrence that track marshals did not spot loose clothing or hair outside a race suit. He said that when he raised this with marshals he would notice an improvement but then see a lapse again.
3. CCTV of the pit lane from 6 August 2021 showed a number of people with long hair hanging loose outside the race suits. The duty manager said that this hair and Ruwaida's headscarf were missed but had no idea why this happened.
4. Capital Karts conduced spot checks and used 'mystery shoppers' as part of the supervision of staff. This system has been used since 2013, i.e. was in operation at the time of Ruwaida's death.
5. There was no evidence about changes to training and/ or monitoring of tracks marshals (asopposed to staff working in reception).
6. My concern is increased by the evidence of Capital Karts' managing director during the inquest. At various points in his evidence he said that, on 6 August 2021, his staff "did their job", followed their training and did the checks they were required to do prior to racing (or words to that effect). As a result of the evidence from the managing director, I have a concern about the nature of Capital Karts' understanding of, and commitment to, addressing the concerns identified in the inquest about the adequacy of checks on clothing performed by marshalls
Responses
Capital Karts
16 Dec 2022
Capital Karts has implemented enhanced safety measures including clear warnings about headscarves and long hair at booking, mandatory witnessed removal of headscarves/loose clothing and securing of long hair at reception, a new safety briefing video, and enhanced marshal training for final grid checks. AI summary
View full response
Dear Madam, Inquest touching the death of Ruwaida Abdi Adam Response to Regulation 28 Report to Prevent Future Deaths

I confirm receipt of your Regulation 28 Prevention of Future Death Report dated 22 October 2022 and this letter has been prepared in response to the matters of concern which you have raised. I shall attempt to deal with all of the matters raised in turn. As you indicate within your report, Capital Karts had already taken steps prior to the Inquest to seek to ensure that there was no possibility of the repetition of the specific events leading to Ruwaida’s death. The evidence at the Inquest was naturally directed principally at the issue of head scarfs and I am grateful to have the opportunity to be able to confirm the wider systems which have been implemented to deal with both loose clothing (including head scarfs) and long hair, which have always been recognised as presenting a risk of injury if they are not removed or secured (as applicable) prior to anyone participating in karting events. The process of providing appropriate safety information now begins at the booking stage. All bookings are made in advance and the response provided by the company with all booking confirmations now includes safety information including a clear warning that head scarves will have to be removed before a person will be able to participate in any karting activity. This warning is repeated in a further communication now sent to the customer prior to their arrival at the venue. This information is reiterated when customers arrive at the venue’s reception. Customers are expressly told that long hair will have to be tied up and head scarfs and other loose clothing will have to be removed. The specific change made since Ruwaida’s accident is that reception staff will, in addition to issuing this instruction, have to directly observe that there has been compliance before any further admittance to the venue is permitted. This is undertaken with appropriate sensitivity so that, for example, a private place will be provided so as to enable a female member of staff to witness a customer’s removal of their head

scarf. If, for any reason, a customer is not able to comply with these requirements, they will not be permitted to participate in any karting activities and a full refund will be provided. A written declaration that covers, amongst other things, that these instructions have been understood and will be complied with must also be completed and signed by all customers over the age of 18 years; and by parents/responsible adults for those participants under the age of 18 years. The pre-race briefing is now conducted by way of a pre-recorded video presentation, which includes specific warnings in relation to long hair and loose clothing. That safety information is further confirmed by notice boards providing the same warnings which are located in the briefing room and the pit lane area. An additional safety check is now also specifically carried out by the Race Director within the briefing area so as to ensure that no customer has any loose clothing or long hair which has not already been removed or secured as applicable. For racers with long hair, this means that their hair, which will have been tied in reception, must be secured within their fastened racing suit. Customers will not be able to leave the briefing area and move to the pit area unless this individual check has been satisfactorily completed. It is therefore no longer possible for any customer to enter the pit area with any loose clothing, including a head scarf, or long hair which has not been secured within their racing suit. The pit lane marshals continue with their pre-race safety checks, which includes helmet checks and a further safety check for any prohibited items, including loose clothing and any long hair outside of the racing suit at both the gate to the racing area and when customers are then seated within their karts. The final warning against loose clothing and long hair is provided by way of the safety decals on the steering wheel on the karts. The kart racing itself continues to be supervised by marshals and by a Race Director, who has access to high-definition cameras, so as to monitor drivers and identify any safety issues which may develop during the race. The current systems are therefore not reliant on checks within the reception area. A series of individual checks are made beginning with the reception area, but then continuing with separate checks within the briefing area; and then the pit area so that it can be ensured that long hair has been secured within the racing suit and has not become untucked, and further that any loose clothing has been removed. Marshals and other staff associated with the racing operations are provided with very comprehensive training manuals and training sessions so as to ensure that they are fully aware of all of their safety duties and responsibilities, including their obligation to ensure that the rules as to loose clothing and loose hair are enforced. Their understanding of those rules and their ability to implement them in practice are also assessed by an experienced Race Director before they are certified as competent to work. Race Directors are also tasked with overall supervision of all racing activities, which includes a requirement to monitor the work undertaken by marshals. Any concerns as to the performance of marshals identified by the Race Directors are promptly addressed. The company does continue to conduct spot checks and use ‘mystery shoppers’ so as to ensure that its expectations as to the performance of its staff are being met in practice. These had not disclosed any issues in relation to the proper undertaking of safety checks by staff prior to Ruwaida’s accident but these checks continue so as to ensure that safety standards are consistently and fully achieved. The evidence in relation to 6 August 2021 did confirm that two customers with long hair had been identified and instructed to secure

their hair within their race suits before they were permitted to begin the karting activity, although, as you note in your report, the track marshals did not identify the head scarf worn by Ruwaida under her helmet as part of their pre-race checks. As set out above, the systems now in place will ensure that such clothing would have been witnessed being removed before a customer would even be admitted into the venue. In respect of my own evidence to the Inquest, I had hoped to convey that the safety of all customers has always been both my and the company’s primary concern, particularly given the inherent risks associated with karting as an activity. I also hope that this was demonstrated by the systems which the company had put in place to ensure that customers were aware of the risks associated with loose clothing and loose hair; the training which was provided to staff; and the checks which were made of each participant before racing commenced. However, notwithstanding that we had believed that our systems were in line with industry standards, we promptly instituted a review following this tragic accident because we were determined to ensure that there could never be a repetition of it. That process led to our implementation of the additional and enhanced safety measures which I have set out above. I sincerely hope that these actions which I have outlined and confirmed in this response addresses the matters which you have raised by way of your report. Everyone associated with Capital Karts deeply regrets the accident and the loss of Ruwaida and we are determined and fully committed to ensuring that a similar accident could never happen again. Should you require any further information relating to my response, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 19 August 2021 I commenced an investigation into the death of Ruwaida Abdi Adan age 15 years. The investigation concluded at the end of the inquest on 13 October 2022.

The jury found the cause of death was: 1a Hypoxic Brain Injury, 1b Asphyxiation

The jury's conclusion was a narrative conclusion: "No safety check ensured that Ruwaida removed her headscarf before getting into her go-cart. No daily mechanics' check was carried out on August 6, 2021. In Ruwaida's cart the plastic drive belt guard to the rear axel was absent and the rear seat shield was damaged. Both should cover exposed moving parts. Ruwaida's scarf became entangled in the moving parts resulting in her asphyxiation and her death on August 10, 2021."
Circumstances of the Death
On 6 August 2021 Ruwaida, age 15, went karting at Capital Karts, Barking as part of a summer programme for young people arranged by Newham Council. On that day she was wearing a religious headscarf.

The evidence at the inquest was that Ruwaida should have been instructed to remove that headscarf and checks should have been done, at various stages, to ensure she removed it.

However, she entered the pit lane wearing the headscarf under the karting helmet and started to race whilst wearing her headscarf. This was not identified by staff at Capital Karts before she began karting.

The jury made findings in relation to the condition of the kart. The evidence at the inquest was that a kart in that condition should not have been driven.

Ruwaida's headscarf became entangled in the kart's moving parts. The headscarf was pulled tight around her neck leading to asphyxiation and ultimately her sad death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.