21 Oct 2013 Brian Belfield · Prevention of Future Deaths report North and West Cumbria
View report summary
Concerns raised 6 Failure to assign single-person responsibility for reconciling race starters, finishers and retirees View source Unavailability of reliable communication between race control and course marshals View source Risk of race-number confusion from using or reusing leftover race numbers View source Failure to investigate inaccurate runner counts View source Failure to monitor runners around the course View source Lack of an accurate race-participant record and race-number check-off system View source See 3 more concerns
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AI-generated summary
Brian Belfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Belfield, aged 63, died from exposure and hypothermia after leaving the Buttermere Sailbeck Fell Race route in poor weather, falling on the fell-side and coming to rest in a pool of water. The race organisers had miscalculated the number of runners and retirees and did not realise he was missing until his wife raised the alarm. Concerns included inadequate recording and checking of participants, unclear responsibility for reconciling race numbers, and unreliable communication between race control and marshals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assign single-person responsibility for reconciling race starters, finishers and retirees
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started. Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired . A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired.
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies.
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused. There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of reliable communication between race control and course marshals
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started. Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired. A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired .
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies.
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused. There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of race-number confusion from using or reusing leftover race numbers
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started. Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired. A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired.
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies.
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused . There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate inaccurate runner counts
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started. Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired. A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired.
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies .
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused. There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor runners around the course
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started. Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired. A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired.
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8 ; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies.
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused. There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Fell Runners Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an accurate race-participant record and race-number check-off system
Wider context from the report “(1) No system was in place to ensure that an accurate record was kept, and referred to, of the participants in the race and those who had retired so that at the conclusion of the race it could be easily ascertained if anyone was missing.
(2) The emphasis was on counting the total numbers of participants and retirees, rather than checking off the race numbers against an accurate record of the race numbers of those who had started . Thus, as happened in Mr Belfield’s case an inaccurate count meant that there was no recognition that one runner was missing.
(3) There did not appear to be any one single person, either the race organiser, or a nominated official in the race organisation, who had the responsibility to check the race numbers of those starting with the race numbers of those finishing, taking into account the race numbers of those who have retired. A single person should have had that responsibility.
(4) There was no reliable means of communication between the race control and the marshals out on the fells so that each of them were aware of the number of participants in the race, those who had retired, and where they had retired.
(5) Thus it was not possible to “monitor” the runners around the course as required by the FRA Safety Requirement number 8; the higher the “risk” to participants in the race, because of terrain, weather conditions, length of the race etc, the higher the need for an effective means of communication, which should be planned into the preparations for the race.
(6) When the marshal at checkpoint 3 notified race control of an inaccurate number of runners who passed through checkpoint 3 there was no consideration or investigation as to the reasons for the inaccuracies.
(7) There is potential for an element of “number confusion” if left over race numbers are used or reused. There should be an emphasis for allocated race numbers to start with the figure 1 rather than the figure 0
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations