Kayden Walker and Ruaridh Stevenson

, the following recommendations are made: i. The Health and Safety Executive, in conjunction with the Adventure Activities Licensing Authority and such government department or departments as may be appropriate, should undertake a formal review of whether commercially provided riverboarding for persons under the age of 18 should fall within the Adventure Activities Licensing regime. That review should consider whether riverboarding may properly be brought within the existing statutory definitions or whether legislative amendment is required. ii. Pending the outcome of that review, the Health and Safety Executive consider issuing specific guidance to providers of riverboarding activities, and to organisations commissioning such activities for children, making clear that riverboarding falls outside the AALA licensing regime. Such guidance should emphasise the need for appropriate and rigorous risk assessment of site-specific hazards by all organisations involved in organising events of this nature. These recommendations are not founded upon a conclusion that AALA licensing would have prevented Kayden Walker’s death. They are made because the evidence disclosed a potentially high-risk commercial adventure activity involving children which presently sits outside an established system of independent scrutiny. Reconsideration of that regulatory position may assist in preventing deaths in similar circumstances. B. Findings in relation to Ruaridh Stevenson: The sheriff, having considered the evidence presented at the inquiry, determines in terms of the 2016 Act as follows:

1. Section 26(2)(a) — when and where the death occurred: Ruaridh Stevenson, born 22 September 1984, died at 1144 hours on 13 April 2024 at the feature known as the Witches Cauldron or the Devil’s Cauldron (“the cauldron”) within Dollar Glen, Clackmannanshire.

2. Section 26(2)(b) — when and where any accident resulting in the death occurred: The accident resulting in Mr Stevenson’s death occurred on the morning of 13 April 2024 within Dollar Glen, Clackmannanshire, while he was guiding a commercial canyoning excursion involving two sisters, Lucy and Jessica Pringle. Mr Stevenson entered the plunge pool to assist Jessica Pringle after she had become caught in the turbulent water beneath the waterfall. He thereafter became caught within the recirculating hydraulic and was repeatedly submerged.

3. Section 26(2)(c) — the cause or causes of the death: The cause of death was: 1(a) Drowning.

4. Section 26(2)(d) — the cause or causes of any accident resulting in the death: The accident was caused by Mr Stevenson entering the cauldron to rescue Jessica Pringle and becoming caught and overwhelmed within the powerful water conditions then present in the plunge pool. The volume and energy of water entering the cauldron were substantially elevated following a period of heavy rainfall. The resulting flow produced turbulent, highly aerated and recirculating water. Mr Stevenson became trapped within that recirculation, was repeatedly submerged and was unable to escape before losing consciousness and drowning.

5. Section 26(2)(e) — precautions which could reasonably have been taken and which, had they been taken, might realistically have resulted in the death, or any accident resulting in the death, being avoided: i. Given the prevailing conditions on the 13 April 2024 a reasonable precaution would have been not to proceed with the excursion through the cauldron. The excursion could have been postponed, relocated to another suitable venue, or conducted by a route which omitted the cauldron. The volume and energy of water entering the plunge pool had materially increased the aeration and recirculating hydraulic within it. Avoidance of the feature would have avoided the circumstances in which Jessica Pringle and thereafter Mr Stevenson became caught in that hydraulic. ii. In the specific circumstances of that day, where the water flow was considerably heightened beyond its usual level, an effective bank-based rescue aid or equivalent pre- rigged rescue system could have been positioned and made immediately available before participants entered the cauldron. Such a precaution might have included a reach pole or a throw line from a pre-rigged rope arrangement. Had such a precaution been taken, it might realistically have enabled Jessica Pringle to be assisted without Mr Stevenson having to enter the water. Such a system may also have provided an external means of support for extraction to Mr Stevenson once he entered the water.

6. Section 26(2)(f) — defects in any system of working which contributed to the death or any accident resulting in the death: i. There was a defect in Adventure Logic Ltd’s system of working in that its risk assessment and operating arrangements did not adequately address, in a site-specific manner, the changing hydraulic risk presented by the cauldron as water levels increased. It was insufficient simply to recognise, at a generic level, the hazards associated with water activities. The risk presented by the cauldron changes with the changing volume and energy of the water flow. Increasing flow altered the aeration levels and the strength of the recirculating hydraulic, thereby reducing the prospect of self-rescue. A suitable system required those matters to be addressed specifically and operationally.

7. Section 26(2)(g) — any other facts which are relevant to the circumstances of the death: The following facts are relevant to the circumstances of Mr Stevenson’s death: i. Mr Stevenson was an experienced and qualified canyoning guide who was familiar with Dollar Glen. He had attended the Glen on 12 April 2024, following several days of heavy rainfall, to assess the conditions. ii. Benjamin Case, an experienced canyoning instructor with substantial knowledge of Dollar Glen, independently attended the Glen on 12 April 2024. On that date, he assessed the water as being at or near an unsafe level and did not take his group of experienced canyoning instructors into the canyon. iii. Once a person becomes caught within the recirculating hydraulic then present in the cauldron self-rescue is highly unlikely, even for an experienced individual. iv. Mr Stevenson was operating as the sole guide for two clients. Solo guiding is not, of itself, inappropriate as a general practice. I do not find that the absence of a second guide is shown to have contributed causally to the accident or death. v. The excursion was not subject to the Adventure Activities Licensing Authority regime because it was being provided to adult participants. There was no requirement for Adventure Logic Ltd’s risk assessment, standard operating procedures, water level criteria or guiding arrangements to be submitted to AALA or any equivalent statutory body for prior approval. I am not satisfied that the absence of external regulation or technical oversight can itself be said to have caused or contributed to Mr Stevenson’s death. vi. There was no warning signage at the cauldron specifically addressing the danger of aerated or recirculating water. I am not satisfied that the absence of such signage contributed to this accident or that signage would realistically have altered Mr Stevenson’s decision to proceed. No finding adverse to the National Trust for Scotland arises from the absence of signage.

RECOMMENDATIONS

8. In terms of section 26(1)(b) of the 2016 Act (recommendations (if any) as to (a) the taking of reasonable precautions, (b) the making of improvements to any system of working, (c) the introduction of a system of working, (d) the taking of any other steps, which might realistically prevent other deaths in similar circumstances), the following recommendations are made: Industry wide recommendations i. The Health and Safety Executive and the UK Canyoning Association should consider producing or developing guidance for commercial canyoning providers addressing site-specific risk assessments, standard operating procedures, and operational water level limits and cutoff criteria. Such guidance should identify the importance of defining the circumstances in which an individual feature should not be used. ii. The Health and Safety Executive and the UK Canyoning Association should consider whether commercial canyoning providers should be expected to obtain periodic independent technical review of their venue specific risk assessments, standard operating procedures and operational water level limits. Any such review should be undertaken by persons with canyoning specific technical competence. The purpose of independent review would be to provide an objective check upon the provider's own systems and reduce the risk of confirmation bias. Cauldron specific recommendations iii. The UK Canyoning Association, in consultation with the National Trust for Scotland, should identify an existing fixed feature or, if necessary, install a suitable water level marker at or near the cauldron from which water levels can be assessed. That would provide a common and objective reference point against which commercial providers can establish and apply water limit cut-off points. iv. Commercial canyoning providers operating at Dollar Glen should incorporate within their risk assessments a venue specific method for assessing water conditions. That system should stipulate an identifiable cut-off point beyond which the cauldron will not be accessed. v. The National Trust for Scotland, in consultation with the local authority as necessary, should arrange for a suitably positioned warning sign to be erected at or close to the cauldron. The signage should draw attention not merely to a general risk of drowning but to the particular danger which can be created by highly aerated and recirculating water within that specific pool and to the increased danger following periods of heavy rainfall. This recommendation is not based upon any finding that the absence of signage contributed to Mr Stevenson's death. It is made prospectively because the cauldron is accessible to the public, has been used informally by adults and children, and presents a serious hydrological danger which may not be apparent to an inexperienced person. NOTE.