“In my judgement, [the Claimant’s] legs were lifted up as a result of the flatness of his trajectory as he went over the side headfirst with his arms outstretched in front of him. He was trying to enter the pool by sliding in over the side as quickly as possible. In my judgement, he was not attempting a manoeuvre which he must or ought to have appreciated was dangerous.”
“After this had happened I thought that one of the personnel had not surfaced after diving into the water.”
“The first time that I entered the pool, I dived in over its side and banged my head on its hard bottom. I hit the top, front part of my head, the part of your head that you would hit if you did a forward roll that went wrong. It hurt when I did it so when I dived in the second time I altered my entry. I managed to control my entry a little better by going in a little shallower and sliding in with my hands out to break my fall. The water was too shallow to dive in the way I had done the first time. It was very difficult to get into the pool and the easiest and quickest way of entry was to run up and dive in headfirst over its side.”
“There was no evidence that the individual who produced the original risk assessment for the game appreciated that contestants might enter the pool headfirst. I am also not satisfied that when Mr Berry reviewed the assessment that he had in mind contestants might enter the pool headfirst. For these reasons I am bound to find that the risk assessments of the game relied on by CL were defective.”
“Both assessments were completed without Flight Lieutenant Taylor knowing in any real detail how the pool game was played or the dimensions of the pool. He understood that it had featured in the previous year’s Health & Fun Day and he saw a photograph of what might have been this event, but he did not know how the game was played and took no steps to find this out. His attitude was that if there were particular risks arising from the pool game, CL would advise him of them. The obligation to prepare an adequate risk assessment was part of the non-delegable duty of reasonable care owed by the MOD to Mr Uren. Flight Lieutenant Taylor was not entitled to leave it to CL to assess the risks of the game. Further, no risk assessment of the pool game could be adequate unless the person undertaking it was aware of how the game was played and the ways the entrants, after being told to exercise care, might enter the pool. It follows that the two risk assessments prepared by Flight Lieutenant Taylor, particularly the second, were fatally flawed.”
“It is obvious that the failure to carry out a proper risk assessment can never be the direct cause of an injury. There will, however, be some cases in which it can be shown that, on the facts, the failure to carry out a proper risk assessment has been indirectly causative of the injury. Where that is shown, liability will follow. Such a failure can only give rise to liability if a suitable and sufficient assessment would probably have resulted in a precaution being taken which would probably have avoided the injury. A decision of that kind will necessitate hypothetical consideration of what would have happened if there had been a proper assessment.”
“The likelihood of harm is gauged with reference to the state of knowledge which could be attributed to the defendant at the time of the occurrence. In Roe v Minister of Health… disinfectant, in which ampoules of anaesthetic were stored, had seeped into the ampoules through invisible cracks. The possibility that this might occur was not generally known at the time of the incident, which occurred in 1947. The claimants, who received spinal injections of the anaesthetic, became paralysed. The hospital authorities were held not liable because the risk to the claimants was not reasonably foreseeable at that date. “We must not look at the 1947 accident with 1954 spectacles” said Denning L.J. In Roe the conduct in question was that of doctors and it was judged according to what reasonable doctors would have foreseen in 1947. In other cases the technical evidence may be less clear as is evident from the conflicting outcomes of The Wagon Mound in which the fire damage was held to be unforeseeable, and The Wagon Mound (No. 2) … in which in relation to the same occurrence, it was held that a small but significant risk of the same fire damage was foreseeable …. Further difficulty may arise where the views of the layman and expert as to likelihood differ. Suppose that the defendant is a layman and that a reasonable layman would foresee a particular kind of harm as likely to result, will special scientific knowledge to the contrary be relied on to hold him not liable, even though this is disproved by the event? If he is held not liable, it would be contrary to the principle that a criterion of foreseeability is the defendant’s standard of knowledge. Conversely, will specialised knowledge be relied on to hold a layman liable for damage which a reasonable layman would not have foreseen? Graham v Co-operative Wholesale Society Ltd … suggests that it will not. The test seems to be the actual or constructive knowledge which a reasonable and prudent defendant would have had if he consulted such literature or made such inquiries as were reasonably expected of him.”
“ … The question of whether a person has acted negligently is not answered simply by analysing what he did or did not do in the circumstances that prevailed at the time in question and then testing it against an objective standard of “reasonable behaviour”
“Nor is the remote possibility of injury enough; there must be a sufficient probability of injury to lead a reasonable person (in the position of the Defendant) to anticipate it.”
“This is clear from classic statements of the law on the standard of care that is expected of people in circumstances where they owe a duty of care to others. In Donoghue v Stevenson, Lord Atkin stated the standard of care that a person must adopt is: “… [to] take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour”
“… it is not enough that the event should be such as can reasonably be foreseen; the further result that injury is likely to follow must be also such as a reasonable man would contemplate, before he can be convicted of actionable negligence. Nor is the remote possibility of injury occurring enough; there must be sufficient probability to lead a reasonable man to anticipate it”
“ … Another word frequently used is “probable.”
“Before Bolton v Stone the cases had fallen into two classes: (1) those where, before the event, the risk of its happening would have been regarded as unreal either because the event would have been thought to be physically impossible or because the possibility of its happening would have been regarded as so fantastic or farfetched that no reasonable man would have paid any attention to it - “a mere possibility which would never occur to the mind of a reasonable man” ( per Lord Dunedin in Fardon v. Harcourt-Rivington - or (2) those where there was a real and substantial risk or chance that something like the event which happens might occur, and then the reasonable man would have taken the steps necessary to eliminate the risk. Bolton v Stone posed a new problem. There a member of a visiting team drove a cricket ball out of the ground onto an unfrequented adjacent public road and it struck and severely injured a lady who happened to be standing in the road. That it might happen that a ball would be driven onto this road could not have been said to be a fantastic or far-fetched possibility: according to the evidence it had happened about six times in 28 years and it could not have been said to be a far-fetched or fantastic possibility that such a ball would strike someone in the road: people did pass along the road from time to time. So it could not have been said that, on any ordinary meaning of the words, the fact that a ball might strike a person in the road was not foreseeable or reasonably foreseeable - it was plainly foreseeable. But the chance of its happening in the foreseeable future was infinitesimal. A mathematician given the data could have worked out that it was only likely to happen once in so many thousand years. The House of Lords held that the risk was so small that in the circumstances a reasonable man would have been justified in disregarding it and taking no steps to eliminate it. But it does not follow that, no matter what the circumstances may be, it is justifiable to neglect a risk of such a small magnitude. A reasonable man would only neglect such a risk if he had some valid reason for doing so, e.g., that it would involve considerable expense to eliminate the risk. He would weigh the risk against the difficulty of eliminating it. If the activity which caused the injury to Miss Stone had been an unlawful activity, there can be little doubt but that Bolton v Stone would have been decided differently. In their Lordships’ judgment Bolton v Stone did not alter the general principle that a person must be regarded as negligent if he does not take steps to eliminate a risk which he knows or ought to know is a real risk and not a mere possibility which would never influence the mind of a reasonable man. What that decision did was to recognise and give effect to the qualification that it is justifiable not to take steps to eliminate a real risk if it is small and if the circumstances are such that a reasonable man, careful of the safety of his neighbour, would think it right to neglect it. In the present case there was no justification whatever for discharging the oil into Sydney Harbour. Not only was it an offence to do so, but it involved considerable loss financially. If the ship’s engineer had thought about the matter, there could have been no question of balancing the advantages and disadvantages. From every point of view it was both his duty and his interest to stop the discharge immediately. It follows that in their Lordships’ view the only question is whether a reasonable man having the knowledge and experience to be expected of the chief engineer of the Wagon Mound would have known that there was a real risk of the oil on the water catching fire in some way: if it did, serious damage to ships or other property was not only foreseeable but very likely. Their Lordships do not dissent from the view of the trial judge that the possibilities of damage “must be significant enough in a practical sense to require a reasonable man to guard against them” ….”
“If a real risk is one which would occur to the mind of a reasonable man in the position of the defendant’s servant and which he would not brush aside as far-fetched, and if the criterion is to be what that reasonable man would have done in the circumstances, then surely he would not neglect such a risk if action to eliminate it presented no difficulty, involved no disadvantage, and required no expense.”
“There are at least two points to note about this important passage. First Lord Reid uses the expression “a real risk”, which was the expression used by the judge in this case. Secondly one cannot in this context separate the enquiry as to reasonable foreseeability of damage from the related enquiry what is it reasonable to do in the light of the reasonably foreseeable risk. It may be reasonable to take no steps to eliminate a risk which is unlikely to eventuate and which will be of small consequence if it does. The social utility of the activity which gives rise to the risk falls to be considered. Carelessly leaking oil into a harbour is an activity of no value from which it is obvious that anyone should desist if it gives rise to only a very small risk of a disastrous fire. Playing cricket on the other hand is a socially useful activity – players should not be expected to desist unless at the location at which the game takes place it poses a risk the nature and extent of which outweigh the undesirability and/or inconvenience and/or difficulty and/or expense of eliminating the risk by stopping play at that ground and/or finding another more suitable location. The latter point emerges clearly from Lord Hoffmann’s speech in Tomlinson ….”
“What is relevant is the degree of likelihood that harm may occur. In Lord Dunedin’s words: “People must guard against reasonable probabilities, but they are not bound to guard against fantastic possibilities.”
“… if you look at the particular mode of entry … you can see that it involves, basically, a horizontal dive from waist height onto a soft and yielding surface and sliding down onto a grassy field. So … instead of looking at … advice which has been given by other people in only vaguely similar situations, I try to get some feel for … what the actual risk is associated with carrying out that activity. So one way of doing that is to look at other activities which are carried out, where people are basically making horizontal dives from about waist height and I don’t have to look very far because I know that [in rugby there are] diving tackles and diving for touch. In my opinion, the risk of diving tackles and diving for touch is actually considerably higher than the risk of diving onto that yielding surface and sliding down a distance of certainly less than one metre, onto what is basically a grassy surface. So in addition … I looked at the statistics for paraplegia and quadriplegia … to see where they were coming from, and most of them come from driving accidents, and there’s a small number, but significant number, which come from sports activities. I think there are about 35 serious cases per year in this country from sports activities. … I’ve got data on how many people take part in these activities and roughly how many times per year, so from that I can get a feel for what the risk is of serious spinal injury - in those situations, in those sports. So that, generally, gives me a feel for how risky this activity might be. I cannot do it any other way. I cannot do it in the abstract ….”
“Correct, yes. But we are still diving from waist height onto the ground, basically. … the way I look at it is that that metre high obstacle actually provides a platform for you to slide over on, which reduces the risk of injury....”
“In my opinion the likelihood of such uncontrolled entry causing sufficient force to cause a serious injury will be greatest where the hands, shoulder, hip or head come into contact with a very firm surface where the momentum of the body is so great to cause a fracture. It is human nature to try to [break] the impact of a fall or similar uncontrolled movement where the body will come into contact with a firm, unforgiving surface by holding out one or both hands. This is seen in everyday life, be it in the children’s playground, in the home, on a sports pitch, or in an industrial setting. Thus I consider that the greatest likelihood from an uncontrolled entry is a sprain or fracture to the upper limb. If the contestant’s trajectory is altered in an involuntary manner during entry then the above rationale remains, in my opinion. We will always try and brake our fall using our hands first. If a contestant is unable to do this then they may fall onto their shoulder, hip or head. I do not consider that an uncontrolled entry whereby the young, fit contestant makes contact with the inflated pool side would give rise to sufficient force to cause serious injury. They may be bruised or winded, or suffer a muscle strain, or similar. An uncontrolled entry whereby the contestant makes contact with the base of the pool as a result of a steep angle of entry would, in my opinion, have the potential to give rise to sufficient force to cause a serious injury, such as a fracture. The likelihood of a fracture of the cervical spine, as that suffered by the Claimant, will depend on the trajectory of the entry, how much the hands and arms would have reduced the momentum of the body, and the angle at which the head hit the pool base. In my opinion the likelihood of this occurring is low. I note from Professor Ball’s report (paragraph 9.7 of his supplementary report) that in his opinion the degree of risk of serious injury entailed in the game as played on the day of the claimant’s accident was tiny.”
“At para 27 he states that a prohibition of headfirst entry would have been an easy and cost free precaution that would have reduced the risk of a serious injury to an acceptable level. I agree that it would have been easy and cost free. However, I am of the opinion that other means of entry carry with them risk of injury that could also have potentially significant injury outcomes. Vaulting means that one hand is placed on the side of the pool. This is a very small area of contact between the competitor and the pool side. If the pool side was wet, as it almost certainly would have been, what was the likelihood of the hand slipping and the competitor falling headfirst or feet or bottom first into the pool? What if the foot or leg struck the side of pool during the vault? Again there is significant injury risk from these uncontrolled falls. Straddling over – i.e. where one leg is swung over the pool side followed by the other produces postural imbalance. Which type of entry would the organiser have allowed?”
“2.1.1 Given the height and width of the cylindrical sides, in attempting a headfirst dive into the pool it is unlikely that the Claimant and others would have been able to clear the obstacle without coming into contact with it. Furthermore, participants would need to move with considerable force to gain sufficient momentum to slide over the barrier in one movement. The required momentum could potentially cause participants to enter the pool at a steep angle, resulting in a heavy landing on the pool base. I also believe that contact with the side will be subject to varying degrees of friction depending upon the interaction of clothing and the extent to which it and the side of the inflatable are wet. … 2.1.3 The fact that the sides of the pool prevented participants from being able to see into the pool, with the possibility of other participants scrambling around the base of the pool searching for a piece of fruit, until the point of take-off could potentially lead to a requirement to re-adjust one’s flight path at the last moment to avoid a collision, thus again potentially leading to a false flight path taking place from a headfirst dive entry. 2.1.4 There is the potential for some bounce effect from the inflatable sides to the pool, when a participant makes contact with it. More than one participant making contact with the side at the same time could increase the bounce effect. This bounce effect would make it more difficult for participants to regulate their method of entry and could lead to a steep entry. 2.1.5 The PVC base lining to the pool, which was covered with water to a varying degree, due to the slope of the field, is likely to have been slippery and therefore when hands were placed onto its surface as part of the forward dive motion there was a reasonably high risk that the participant’s hands would slide away from them, which in turn would cause a loss of control and a sudden readjustment in body positioning and a greater likelihood of their head coming into contact with the base lining of the pool.”
“It is of course understandable that organisations like the Royal Society for the Prevention of Accidents should favour policies which require people to be prevented from taking risks. Their function is to prevent accidents and that is one way of doing so. But they do not have to consider the cost, not only in money but also in deprivation of liberty, which such restrictions entail. The courts will naturally respect the technical expertise of such organisations in drawing attention to what can be done to prevent accidents. But the balance between risk on the one hand and individual autonomy on the other is not a matter of expert opinion. It is a judgment which the courts must make and which in England reflects the individualist values of the common law.”
“25. Moving across the 0.98 [metre] width of the pool wall would also have presented a challenge, needing forceful effort and momentum from the run up for competitors to propel themselves across the wall. This would have interacted with possible movement, deformation and bouncing of the pool side wall itself, this not being a rigid structure. The trajectory of each competitor’s body across the pool side would have depended on the trajectory of the competitor’s launch and the distance into the width of the pool side where their body first made contact. This will have varied from one competitor to another, affected by the speed of their run up and the distance from the pool at which they launched. Another possible factor affecting a competitor’s trajectory was the pool side flooring being wet and slippery. 26. An energetic run up, with a vigorous launch, with the body first making contact with the pool side at a distance from its outer edge, would have had clear potential to present competitors with difficulty controlling their entry into the water. A steep angle of entry could occur from this, also with the possibility of axial rotation. The trajectory of the competitor’s entry into the pool carried a high degree of uncertainty. [He then referred also to the variations in friction arising from the varying amounts of water on the pool side and to the fact that the depth of the water would have had no attenuating characteristics.] 30. The unpredictable trajectory of competitors across the pool side, together with the forward motion and momentum of their bodies, would have presented difficulties for some competitors controlling their speed and direction of entry into the pool. In my opinion, this posed a clear possibility of a headfirst impact with the bottom of the pool. It is well known that the cervical spine (neck) is vulnerable to serious injury from head impact and axial loading.”
“In my opinion there was a ‘very high’ or ‘substantial’ risk of serious injury entailed in the game as played. This takes into account that there was the potential for ‘extreme harm’ i.e. major fracture and injury that would cause substantial disability. I assess the likelihood of harm occurring as ‘likely’. The terminology I have used here is taken from risk assessment guidance by HSE and IOSH, using their approach to categorising the potential severity of harm and classifying the likelihood of harm occurring. After the event, it is beyond doubt that headfirst entry into the pool had the potential for serious harm. This occurred with [the Claimant] …. Considering the risk of serious harm ex-ante, it is well known that headfirst impact with the ground at a steep angle carries a high risk of cervical fracture. With the game as played, I believe there was a significant foreseeable possibility of forceful steep angled headfirst impact for the reasons given in my previous reports …. I have said that in my opinion there was a “very high” or “substantial” risk of serious injury entailed in the game as played. In plain language, I believe this was a serious accident waiting to happen.”
“In my opinion, as an obstacle the sides of the pool could have been reasonably safely negotiated by climbing or by vaulting. However, even outside the leisure industry, it is well known that it is dangerous to dive into the shallow end of a swimming pool. The hazard of a headfirst entry is the same albeit the risk of injury from a relatively fast headfirst dive is likely [to be] greater than the risk associated with a slow headfirst entry (eg slowing sliding in headfirst over the side). Due to the likely difficulty in differentiating between slow headfirst entries and fast headfirst dives during the course of the game, it would probably have been advisable to ban all headfirst entries at the outset of the game.”
“In my opinion, while explaining the game rules [CL] should have ensured that the competitors were verbally warned not to enter the pool headfirst, in particular to dive. If competitors were diving headfirst into the pool during the game, this should have been immediately discouraged or penalised by those in charge …”
“The judge said that he thought that what spectators thought of the risks of the game was of very little relevance. I am afraid that I do not agree with him on that. This was a game which no-one had seen played in this way before. There was no evidence that anyone from CL had seen it played in this way, permitting headfirst entry. No-one from the RAF had seen it played until the day of this accident. None of the experts ever saw it being played; they all had to envisage it. It seems to me that the impressions of those who actually saw it that day were potentially important.”
“Although it is plain that a game involving the pool had been provided in 2004, it is not clear that the very same relay game was played on that occasion. The view in PEd Flt was that the package of games had been a success in 2004 but no-one was certain what the pool game involved.”
“Mr Berry had supervised the pool game once before; Messrs Brent and Brill had no previous experience of the game.”
“CL’s evidence was that this pool was not often hired out as it required a great deal of water. Indeed, there does not appear to have been any evidence that this game had ever been played before using this pool. The risk assessment, as modified (if it was) by Mr Berry made no reference at all to methods of entry and there was no evidence that the person responsible for the original assessment appreciated that participants might enter the pool headfirst. Mr Berry had not seen this game played and had not applied his mind to the question of how participants would enter and leave the pool.”
“… the pool is not featured in the company brochure because of potential difficulty in supplying water and also emptying the pool after an event. In fact, I think the RAF event may have been only the second occasion on which I have attended an event where the pool was supplied. The first was in Yorkshire for Water Aid.”
“I had previously assisted in this game and on one occasion, I believe the previous year, at RAF High Wycombe.”
“The medical evidence fits better with [the Claimant] sliding headfirst over the wall and becoming almost vertical before striking the unyielding plastic-covered ground. His trunk was still behind his head when he struck the ground and became limp, resulting in him falling prone. He had sufficient forward momentum at the time of impact to carry his limp body across the pool to the far wall.”
“The CT, MRI and plain films … indicate that he sustained a burst fracture of the body of C5 with a minor degree of anterior wedging at this level. The other skeletal injuries were minor in comparison with the C5 vertebral body. The burst fracture caused his spinal cord injury. Burst fractures at C5 are caused by axial loading to the top of the head. The minor anterior wedge of C5 indicates that there was a minor element of forward flexion of his head on his neck at the time of impact, but the large majority of the energy vector was axial loading. To produce a C5 burst fracture the top of the head must strike an object with sufficient energy to cause the body of C5 to burst like a round meringue on which a fist descends.”
“The most common injury site of diving accidents is the cervical spine, involving particularly fractures of vertebrae C5 or C6. Injury to these vertebrae usually results in tetraparesis or tetraplegia respectively. The C5 and C6 segments are more prone to injury because they form the functional axis of rotation between the head and the trunk and are capable of a large range of motion. This is further exacerbated by the smallness of the spinal cord, the minimum protection offered by bones and soft parts, and minimal flexibility of the actual spinal canal. Fractures caused by flexion with or without axial compression, often occur in diving accidents. The most common of these fractures are wedge fractures and compression fractures. A wedge fracture can result from either hyperflexion or from an off-centre impact of the top of the head with the pool bottom. The wedge fracture is the result of pressure exerted on the anterior elements of the vertebral body, causing it to be wedged between adjacent segments. A compression fracture occurs when the vertex of the head directly impacts the pool bottom. The vertebral body is fractured as the compression is increased. In some cases, the anterior inferior angle of the vertebral body may be chipped away. The anterior smaller fragment may displace forward and result in a ‘teardrop’ fracture. Alternatively, posterior displacement of an intervertebral disc or partial dislocation of the posterior vertebral fragment into the spinal canal may occur causing spinal cord compression. The severity of injury is also dependent upon the amount of neck flexion caused by additional bending of the neck as the diver’s body continues in motion. Hypertension spinal injuries can also result from flat, headfirst dives into shallow water, or by trying to slow the dive by suddenly extending the neck just prior to contacting the pool bottom. The neurological lesion may be exacerbated by water rescue methods because of instability of the spine after injury.” instability of the spine after injury.”
“very unlikely” is given 1, “unlikely” 2, “possible” 4, “probable” 6, “very likely” 8 and “certain” 10; the same gradation applies for “no injury”, “minor injury”, “3-day” injury, “major injury”, “single death” and “multiple death”