Brian Belfield · Prevention of Future Deaths report

On 2 May 2012 I commenced an investigation into the death of Brian Belfield, aged 63. The investigation concluded at the end of the Inquest on 26th September 2013. The conclusion of the inquest was:

The Cause of death was:
1.a. Exposure and Hypothermia

The Narrative Conclusion was:

On the 29th April 2012 Mr Belfield registered as a competitor in the Buttermere Sailbeck Fell Race. He was a seasoned fell runner and had run this race in previous years. During the course of the race the weather became very poor with cold temperatures, high winds, driving rain, and poor visibility, particularly on the route between Causey Pike and Crag Hill.

At some point between Sail and Crag Hill Mr Belfield left the race route and descended the fell-side at a place called Scar Crag. This was a difficult place to descend without good knowledge of the area, and especially in the poor prevailing weather conditions. There was no recognised track or path at this point to the bottom of the valley. It is likely that Mr Belfield took this route in order to shelter from the poor weather conditions and as a means of retiring from the race and returning to Buttermere.

During the course of the descent Mr Belfield slipped on slippery moss falling and sliding a number of feet on his back, and in the process suffering abrasions and concussion. He came to rest in a pool of water from a stream, and it appears he became unconscious and died as a result of exposure and hypothermia. His death would have occurred shortly after his fall. After a search by a Mountain Rescue Team and an RAF helicopter he was found the next day.

The organisers of the Race had miscalculated the number of runners and those who had retired and as a result they had not realised that Mr. Belfield was missing until his Wife had raised the alarm when he had not returned to their lodgings.

As set out in the Narrative Verdict, above.

(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