Marion Clode

PFD Report All Responded Ref: 2021-0228
Coroner Karen Dilks
All 2 responses received
Coroner's Concerns (AI summary)
The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn the public of risks. Insecure holding pens and an unutilised gate design contributed to the danger.
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In the circumstances it is my statutory to report to you. Cattle movement being commonly undertaken in accordance with individual farmers "custom and practice" and in the absence of: a) formal plans for cattle movement (written or verbal) b) Contingency planslstrategies in the event of cattle breakout c) Specific planning in respect of the heightened risk associated with the presence of young calves and in the context of their first release from winter shed (2) Cattle movement undertaken without appropriate measures in place to mitigate the risks of cattle breakout: a) Cattle held to movement in a holding area pen which was insecure. Cattle contained only by quad bike and trailer (driven by farmer) at the front of the herd. b) No warning to the public of impending cattle movement and the risks thereof either by temporary warning signage or farm staff place at strategic points on the planned route to give verbal warning: her duty prior

(3) Secure at the entrance to bridle way unable to be utilised due to direction of opening which with some limited alteration may have gone someway to mitigate the risk in this case.
Responses
J M Nixon Son
29 Dec 2020
Action Taken
J M Nixon Son has revisited and made changes to its cattle movement plan, including no longer using a second holding area, implementing a new quadbike system for checking the track for public, and placing 'Warning Cattle being Moved' signs. (AI summary)
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Dear Karen L Dilks LLB Thank you for your letter dated 7 2021 attaching the Regulation 28 Report to Prevent Future Deaths dated 29 December 2020. propose to address the coroners Matters of Concern before going on to set out the current plan for the movement of cattle. Matters of Concern Cattle movement commonly undertaken in accordance with individual farmers "custom and practice" and in the absence of: (a) Formal plans for cattle movement (written or verbal); (b) Contingency plans strategies in the event of cattle breakout; (c) Specific planning in respect of the heightened risk associated with the presence of young calves ad in the context of their first release from winter shed, In relation to the suggestions that there was an absence of a formal plan for cattle movement, contingency plan or specific planning to take into account the presence of young calves, would wish to make the following observations Having heard all of the evidence, the HSE expert witness, confirmed in his evidence to the court that; in his opinion, the plan in place for the movement of the cattle was a reasonable one. In particular; he confirmed it was his view that the drive along the track to check for members of the public was carried out within a reasonable timeframe In relation to my contingency plan lagreed that had a contingency plan in place and that the plan to follow the herd, enter the field on the left hand side by the metal and travel up the field in order to overtake the cattle, was a reasonable one_ An experienced cattle farmer; also answered questions at the Inquest about the plan: He confirmed his view that plan to move cattle has to be flexible. He also stated that; as one cannot predict what might go wrong, any contingency plan involves weighing up the risks at the time: In answer to a specific question about a breakaway group that disappear from view; he responded by saying that he would try to around and past them; but that if that wasn't possible, he would go slowly and ensure that he didn't push them further away maintain that a plan for the movement of the cattle was in place at the time of the incident and that it was one that had been used for many years_ without incident That plan very much took into account the fact that young calves would be in the group of cattle that were being moved. Further, there was a reasonable contingency plan in place: May being gate any get

Cattle movement undertaken without appropriate measures in place to mitigate the risks of cattle breakout (a) Cattle held prior to movement in holding area pen which was insecure_ Cattle contained only by quadbike and trailer (driven by farmer) at the front of the herd; (b) No warning to the public of impending cattle movement and the risks thereof either by temporary warning signage Or farm staff placed at strategic points on the planned route t0 give verbal warning: When giving evidence at the Inquest; stated that in view the method of using the quadbike and trailer; together with my being at the side of those with the flexible stick; was a reasonable practice It is accepted that at the time of the incident there was no temporary signage in place, as it was believed that check of the route prior to the movement commencing was sufficient: No guidance issued by the H.SE. suggests that signs should be used when moving cattle Secure at the entrance to the bridleway unable to be utilised due to direction of opening which with some limited alteration may have gone some way to mitigate the risk in this case The opens "inwards" (ie towards the sheds rather than away from them down the track) During a visit from representatives of the H.SE: on November 2020, it was discovered that; following some significant alterations, the gate can be opened outwards (away from the sheds) However it has to be lifted, with significant effort over the slope of the ground because of both the gradient of the track and its camber: That is, the gradient and camber are such that the gate hits the ground and cannot be pushed any further without it being lifted: This would clearly cause problems, and potentially increase the risk of cattle breaking out, if it were done at a time when cattle were about to be moved along the bridleway: This is the reason the hadn't been altered previously_ As explained in evidence at the Inquest; the use of the gate no longer forms part of the cattle movement plan (see below): Details of action taken to address the coroner'$ Matters of Concern Whilst maintain that there was a plan in place at the time of the incident have revisited the plan and changes were made following the incident: The plan is not required to be documented but all parties involved understand the plan their role in it There are two cattle sheds. Each shed has its own secure holding area the cattle are moved out of the shed into the secure holding area immediately outside it That is the same as before. However, as stated at the Inquest hearing, cattle are not now moved into a second holding area requiring the use of any barrier at the entrance to the bridleway: That second holding area the gate are no longer part of the movement plan: Cattle are moved one shed at a time So there is no need for this second holding area The gate to the bridleway is left open and ride my quadbike along the track to check the gates along it ad to warn any walkers on the track As explained during my evidence at the inquest, then return to the brow of the first hill. From this point can his the gate gate 17t gate and and and

see if any members of the public come along the track in the period between my check and the cattle being moved. If see any members of public, will ride to them and warn them of the imminent cattle movement or wait until are clear there are none will call the staff members in the holding pen and tell them to commence moving the cattle (as long as it is clear where are): There are always two members of staff moving the cattle from the holding pen to the bridleway and then, depending on the numbers of cattle, either one or two will follow the cattle up the track to the field. Once the move has started stay well ahead of the cattle (around 200m 300m) so that if anyone comes onto the track have plenty of time to them to stand in a field until the cattle have passed. We also now have "Warning Cattle being Moved" signs which are placed around the farm yard to warn any members of the public coming up behind the sheds that cattle are being moved ahead of them:
Department for Environment, Food and Rural Affairs Central Government
1 Jul 2021
Action Planned
Defra is undertaking reforms to the rights of way system, including a 'Right to Apply' provision for landowners to divert or extinguish paths and guidance to encourage removal of paths from private areas. The response also details HSE's existing investigation procedures and analysis of cattle incidents. (AI summary)
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Dear Ms Dilks, am writing in response to the 'Regulation 28' report dated on 29 December 2020 and sent to our offices on
2021. On behalf of the Department for Environment; Food and Rural Affairs (Defra) , would like to take this opportunity to acknowledge the concerns you have raised regarding the tragic incident which resulted in the death of Marian Clode on 2 April 2016. Defra are undertaking a package of reforms to the rights of way system which will lead to improvements in various areas, including an improved capacity for landowners to move certain rights of way on their land. Under provisions known as the 'Right to Apply' , landowners will be able to make formal applications to local authorities to extinguish or divert rights of way from their land with a right of appeal to the Secretary of State if the authority refuses or fails to respond. These applications will be considered on a case by case basis the outcomes cannot be guaranteed. Guidance will however encourage local authorities to remove public rights of way wherever possible from premises where privacy, safety and security are of a significant concern, including family gardens and working farmyards We have discussed the details of this specific case with the Health and Safety Executive (HSE) , Britain's national regulator for workplace health and safety: HSE is the enforcing authority for incidents involving cattle on farms. HSE are already aware of this case and have provided the below information relevant to this situation. An overview of HSE procedures is published online: https IIwWWhse Gov_Uklfoilinternalops/og/ogprocedureslindexhtm HSE investigates incidents following a specific procedure for this type of incident. https IIwww hsegov uklfoilinternalopslog/og-00058.htm and determines if farms have established control methods giving consideration to their Agriculture Information Sheet (AIS) 17 (https:IIwWWhsegov uklpubnslais]Zewpdf) and other documented standards. Idisability confident UeADefl May and

The legal duty on the farmer under the Health and Safety at Work etc Act 1974 is to manage their herd so the animals within it present a low level of risk to members of the public using public rights of way: HSE's published guidance sets out the hierarchy of control measures would expect the farmer to have considered and where possible implemented, before considering additional measures such as offering a voluntary alternative route_ Examples of control measures include eliminating the risk by grazing cattle in fields without public access or segregating people from the cattle by use of fixed or temporary fencing; keeping cows with young calves in other fields; arranging field infrastructure so that animals and people are kept apart (e.g. feed and water away from the path or stiles); moving animals from fields with paths at times (e.g. bank holiday weekends): HSE analyse and review cattle incidents each year looking for potential trends which are published each year: https:IIwWw_hse gov uklaboutuslmeetingsliacslaiaclindex htm: HSE has engaged with Natural England to look at cattle data; to enable them to analyse if there are patterns in land use that are prevalent with regard to incidents. Natural England administers grant schemes so that farmers could be paid to consider alternative land management methods that reduce the risks to walkers_
Sent To
  • JM Nixon Ltd, Swinhoe Farm Belford Northumberland
Response Status
Linked responses 2 of 1
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

Report Sections
Investigation and Inquest
On 7 April 2016 commenced an investigation into the death of Marian Elizabeth CLODE: The investigation concluded at the end of the inquest on 22 October 2020 The conclusion of the inquest was Accident Medical Cause of Death 1a CARDIAC ARREST WITH ANOXIC-ISCHAEMIC BRAIN INJURY 1b
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.