FAI DETERMINATION SUMMARIES

Sheriff O’Mahony found there were precautions which could reasonably have been taken that might realistically have resulted in the deaths being avoided.

The Sheriff has made recommendations with the aim of preventing other deaths in similar circumstances.

The Sheriff's full determination is available to read on the Scottish Courts and Tribunals website and is the only authoritative document.

Kayden Walker

Background

Kayden Walker was born on 16 January 2007 and was 12 years old at the time of his death.

Kayden attended and used the services of Church House, a registered charity based at the Bridgeton Family Support Centre, Glasgow, which provides programmes and activities for children, young people and families.

Kayden had previously taken part in several organised water-based activities, including kayaking, paddleboarding and whitewater rafting. Although he had limited swimming ability, those who observed him during previous activities described him as enjoying water sports and being confident in the water.

Having sought parental permission from attendees, Church House organised for Outdoor Pursuits Ltd to lead a riverboarding activity on the River Tay in Perthshire on 28 July 2019.

The company's sole director, Philip Robinson, participated in the activity alongside another instructor, Callum Gracie.

The group were to navigate a three-kilometre section of the river, with Mr Robinson leading on a body board and Mr Gracie in a kayak. The first significant feature they encountered was Stanley Weir.

A weir is a low barrier built across a river to raise the upstream water level and control the flow of water downstream. Unlike a dam, which stores water in deep reservoirs, a weir allows water to spill freely over its top edge. Stanley Weir had previously been identified as hazardous.

Kayden was among the last to approach the weir. After escorting two other children, Mr Gracie took up position approximately fifteen feet downstream. He watched two adults from Church House navigate the feature before Kayden's board resurfaced without him.

Realising Kayden had not descended, Mr Gracie immediately paddled back upstream. He found Kayden trapped underwater, describing his legs as being ‘hair pinned’ around branches.

After initially failing to release him, Mr Gracie entered the water, placed a sling beneath Kayden's legs and used a sawing motion to free him.

Kayden was then carried downstream by the rapids, where Mr Robinson, who had been traversing upstream, caught him and immediately began CPR.

Emergency services attended and Kayden was taken to Ninewells Hospital in Dundee, arriving at 1550 hours.

On 29 July 2019, he was transferred by air ambulance to the Royal Hospital for Sick Children in Glasgow. His condition deteriorated and he died at 1510 hours that day.

The cause of death was determined to be hypoxic/ischaemic brain damage due to drowning.

The local authority subsequently submitted a report to the Crown Office and Procurator Fiscal Service recommending prosecution of Outdoor Pursuits Ltd under the Health and Safety at Work Act 1974.

Outdoor Pursuits Ltd pled guilty at Perth Sheriff Court on 21 October 2024.

Findings

Sheriff O’Mahony noted that Outdoor Pursuits Ltd had prepared a risk assessment in advance of the activity. However, it was not site-specific and referred to riverboarding at four different venues, including the River Tay at Stanley.

While the assessment addressed the risk of participants' boards becoming trapped, it did not identify the risk of individuals themselves becoming trapped.

As part of its guilty plea, Outdoor Pursuits Ltd conceded that its risk assessment was not suitable and sufficient. It failed to identify a safe system of work for negotiating the weir, specifically the need for guides to be positioned both above and below it.

Sheriff O’Mahony concluded that the deficiency was not a failure to predict the precise underwater object which trapped Kayden, but a failure to identify the type of catastrophic hazard known to be present at that location and to outline a system designed to control exposure to it.

The Sheriff concluded that the risk assessment was not suitable and sufficient in that limited but material respect.

Had the risk of body or limb entrapment at Stanley Weir been expressly assessed, it should have resulted in a corresponding method of work, including positioning instructors above and below the weir until all participants had passed safely.

The sheriff identified two precautions which could reasonably have been taken, and which might realistically have avoided the accident or death.

The group could have left the river upstream of Stanley Weir, past the feature by walking along the adjacent riverbank, and then re-entered downstream.

Additionally, one instructor could have remained upstream and another downstream until all participants had safely negotiated the weir.

This would have provided supervision and rescue cover on both sides of the hazard. That formation would have materially reduced the risk at the weir.

The inquiry also considered the Adventure Activities Licensing Authority (AALA) scheme, which applies to four categories: climbing, caving, trekking and water sports.

The scheme covers canoes, kayaks or similar hand-paddled craft, rafts and certain sailing craft. Riverboarding does not fall within those definitions and is therefore not a licensable activity under the AALA regime.

Sheriff O’Mahony did not find that the absence of AALA licensing caused or contributed to Kayden's death. However, he considered the regulatory gap relevant to the forward-looking function of the Fatal Accident Inquiry.

Recommendations

Sheriff O’Mahony recommends that the Health and Safety Executive, in conjunction with AALA and any relevant government departments, undertake a formal review of whether commercially provided riverboarding for persons under 18 should fall within the adventure activities licensing regime.

The review should consider whether riverboarding can be brought within the existing interpretation of statutory water sports categories or whether legislative amendment is required.

Pending the outcome of that review, the Sheriff further recommends that the Health and Safety Executive consider issuing specific guidance to providers of organised riverboarding events for children.

This guidance should draw attention to the fact that riverboarding is currently outside AALA licensing requirements and emphasise the need for appropriate and rigorous risk assessments of site-specific hazards by all organisations involved in organising such events.

Ruaridh Stevenson

Background

Ruaridh Stevenson was born on 22 September 1984 and was 39 years old when he died on 13 April 2024.

In October 2023, Mr Stevenson and his wife established Adventure Logic Ltd, of which he was a director and instructor. He specialised in private canyoning tours and experiences at locations throughout Scotland, including Dollar Glen, where he regularly operated.

The excursion on 13 April 2024 originated as a 21st birthday present for Lucy Pringle, who had received two vouchers for a canyoning experience from her step-grandmother. She decided to bring her sister, Jessica Pringle.

Both sisters had previously participated in canyoning activities, although neither had done so at Dollar Glen.

Dollar Glen, in Clackmannanshire, is owned and conserved by the National Trust for Scotland. Open to the public, it is known for its wooded gorge, waterfalls and walks.

One of its best-known features is a plunge pool known as the Witches Cauldron or Devil's Cauldron (“the cauldron”).

Situated beneath a waterfall, the cauldron is approximately three metres deep and two metres wide, bounded by rock.

Its hydraulic characteristics are particularly significant. As water levels rise, the water becomes increasingly aerated, reducing effective buoyancy. The shape of the pool can also create a circulating current which draws a person back towards the waterfall rather than allowing easy escape downstream.

Heavy rainfall can rapidly transform the canyon, creating powerful waterfalls and turbulent pools. Several days of heavy rainfall had occurred in the Dollar area immediately before 13 April 2024.

On the day of the excursion, Lucy and Jessica met Mr Stevenson, who was their sole guide. They received instructions, familiarisation with the equipment, and safety and participation forms.

When the group reached the cauldron, Mr Stevenson descended first without apparent difficulty. He then instructed Jessica to descend.

Jessica entered the waterfall in essentially the same manner Mr Stevenson had demonstrated. However, on entering the pool, she became submerged and did not immediately reappear.

After several seconds, Mr Stevenson appeared to recognise she was in difficulty and entered the pool to assist her.

Lucy remained above the waterfall while Mr Stevenson and Jessica became caught in the powerful current. She saw them repeatedly disappear beneath the water and briefly resurface.

Jessica eventually escaped, but Mr Stevenson remained in difficulty.

Lucy threw a rope towards him, but the current carried it away before he could secure it. He was pulled underwater again and resurfaced approximately 45 seconds later, unconscious, near the side of the pool.

Lucy managed to take hold of him but could not remove him from the water unaided.

Two walkers then came upon the scene and helped Lucy remove Mr Stevenson from the water onto the rocks, where CPR immediately commenced.

Emergency services were called. Due to the steep and confined terrain, Mountain Rescue and the Scottish Fire and Rescue Service attended, and an air ambulance response was arranged for evacuation.

Resuscitation efforts continued for more than an hour, but Mr Stevenson remained unresponsive.

He was pronounced dead at the scene at 1144 hours on 13 April 2024.

His cause of death was certified as drowning.

Findings

Sheriff O’Mahony found that the excursion on 13 April 2024 should not have proceeded through the cauldron because of the depth, volume and force of the water entering the plunge pool.

The appropriate course would have been to postpone the excursion, relocate it or omit that feature.

The risk assessment was found to be generic in character and lacking site-specific detail. It did not reference the cauldron or set out how the feature should be managed.

In Sheriff O’Mahony's view, the failure to provide a site-specific system for assessing the changing hydraulic risk at the cauldron amounted to a defect in the system of working.

He also found that a reaching aid, such as a pole or suitable branch, positioned for immediate use at the cauldron might realistically have enabled assistance to be given to Jessica without Mr Stevenson entering the water.

The Sheriff was satisfied that this was a precaution which might realistically have avoided his death.

Recommendations

Sheriff O’Mahony made a number of recommendations intended to improve safety in commercial canyoning and reduce the risk of further deaths.

These include a recommendation that the HSE develop guidance for commercial canyoning providers on risk assessments, water level limits and water depth cut-off points.

Specifically, in relation to the cauldron at Dollar Glen, he recommended that a water depth marker be installed to provide additional guidance to those who are carrying out activities there.

The Sheriff did not find that the absence of warning signs at the cauldron contributed to Mr Stevenson's death. Nevertheless, he has recommended that the National Trust for Scotland erect warning signs drawing attention to the specific dangers found there.

The Sheriff's full determination is available to read on the Scottish Courts and Tribunals website and is the only authoritative document.