Glenridding Beck investigation
What you will find on this page
- A summary of the investigation into Max Palmer's death;
- The key findings, and a link to download the full investigation report.
What you should know
The Facts - What happened?
Max Palmer, a 10 year old Lancashire schoolboy, died while 'plunge pooling' during an activity weekend. His mother and another pupil were airlifted to hospital.
Glenridding in Cumbria
The weather was poor. The stream was in spate. The water was very cold and, most of all, there were serious deficiencies by the party leader in planning and leading the activity.
The plunge pooling session involved jumping 4 metres into a rock pool in a mountain stream and swimming to an exit point. The group leader jumped in first. He said it was alright. Soon afterwards, Max jumped in. As soon as he surfaced, he was in difficulties and unable to get out. The leader jumped in to rescue him but, after several minutes, was overcome by the cold. Max's mother, who was accompanying the visit, also attempted a rescue, but she too was gradually overcome by the cold. She was rescued by a pupil who also suffered from hypothermia. Both he and the mother were airlifted to hospital. Max was washed over the weir at the exit to the pool and tumbled down the raging beck. He was pulled out by other pupils, but pronounced dead at the scene.
The report summarises the very detailed investigation by HSE and Cumbria Police into the tragedy at Glenridding Beck. It shows that the chain of events leading to the tragedy began long before the fateful weekend and shows how compliance with existing guidelines and practice prevents such chains developing. The report emphasises the importance of having effective health and safety management systems and guarding against individual and institutional complacency. It also demonstrates the importance of pupil involvement in organising safe and successful educational visits.
The report states the facts and, against them, makes comments and recommendations to help users identify good practice.
Getting it right
HSE fully recognises the value of the personal development that can be achieved through well-planned adventurous activities and is a firm supporter of outdoor education. It is important that activities are properly planned and sensibly managed. Most teachers are careful and professional but everyone can learn the lessons from this report, undertake proportionate risk assessments and run activities sensibly.
Follow the existing guidance - The existing guidance has grown out of the lessons learned from previous tragedies. There is lots of useful information elsewhere on the AALA website.. It is likely that the chain of events that led to the Glenridding tragedy would have been interrupted at an early stage had the existing guidance been followed.
Take account of the lessons from the Glenridding tragedy.
The investigation clarified thinking in a number of areas. It identified areas of good practice that were known to specialists, but deserved wider circulation. These topics are summarised below.
- There is an increasingly diverse range of activities and trip organisers need to have policies and procedures which cover the eventuality of groups wanting to do activities for which there are no National Governing Body (NGB) standards or qualifications
- Competence is wider than just the holding of qualifications. Competence to lead a particular activity needs to be assessed by a technical expert. The fact that somebody has done an activity before does not necessarily mean that they are competent
- Identifying appropriate the correct supervision ratios is not just a matter of applying a simple numerical calculation of leaders to participants but must be based on proper consideration of both the activities and the participants;
- Generic and site-specific risk assessments should identify "cut-off" points to inform dynamic risk assessments
- There is a need for policies and procedures in respect of leaders and helpers wanting to bring additional children.
- Leaders and others should never create unrealistic expectations
- The need for a "Plan B" to provide alternative activities if the main objective cannot be delivered
- Where water activities are involved, the need to give due consideration to the forseeability of 'panicking swimmers' and to provide the necessary precautions
- The value of high levels of participant involvement in decision-making to ensure that risks and control measures are properly discussed and participants learn to be "risk aware" rather than "risk-averse"
- The importance of managers providing clear monitoring arrangements for both administrative procedures and activities in the field.
What about "lower risk" visits?
You can find information about lower risk visits on our school trips pages.
One of the main lessons we want you to learn from Max's death is how to ask the right questions and to adopt controls that are proportionate to the risk for any adventure activities that you may be involved in. The majority of adventure activities probably involve lesser hazards than the activities described here. Adopting a sensible approach to health and safety means recognising that no "one size fits all" for visits. Whatever the visit you are involved with, the principles of control outlined in this report will be relevant. These include use of guidance, risk assessment, participant involvement, parental consent, formal approval, leader competence and appropriate supervision. The risk assessment should indicate the appropriate levels of control.
What do I do now?
Make sure you ask questions about any proposed adventure activity trip.
Please feel free to use the Investigation Report as a case-study for training or as a reference for evaluating your procedures.