INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF PETER PAUL COYLE
SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES AND GALLOWAY AT HAMILTON
[2017] FAI 7
B265/16
DETERMINATION
BY
SHERIFF SHIONA A WALDRON
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRIES (SCOTLAND) ACT 1976
into the death of
PETER PAUL COYLE
Hamilton, January 2017
The Sheriff having heard evidence and having resumed consideration of the cause, Determines in terms of section 6 of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 that:
[1] In terms of section 6(1)(a) Peter Paul Coyle who was born on 1 November 1957, died at Quarter Fishery, Limekilburn Road, Quarter, Lanarkshire, on 22 January 2015 about 5.00 pm.
[2] In terms of section 6(1)(b) of the 1976 Act the cause of his death was drowning.
[3] In terms of section 6(1)(c) of the 1976 Act the death might have been avoided if Mr Coyle had not taken a damaged boat out alone on the frozen pond; in the absence of knowing why he did so, there is no reasonable precaution identified whereby his death might have been avoided.
[4] In terms of section 6(1)(d) of the 1976 Act there is no finding about defects to any system of working which contributed to the death.
[5] In terms of section 6(1)(e) there are no other facts which are relevant to the circumstances of the death.
Findings in Fact
[1] The late Peter Paul Coyle was born on 1 November 1957 and was 57 years old at the time of his death on 22 January 2015. He was single and lived alone at 5 Wilkie Loan, Bellshill. His next of kin are his six brothers and sisters. He was in receipt of incapacity benefit at the time of his death. During his working life, Mr Coyle worked in the hotel and catering industry and was also at one time a singer who had travelled all over the country singing professionally. Mr Coyle could not swim.
[2] Quarter Fishery is a trout fishing pond and adjacent land approximately 2 acres in area, situated near the village of Quarter in Lanarkshire about 10 minutes from the town of Motherwell. It is approximately one quarter of a mile from the main road, Limekilburn Road, Quarter and is accessed by a private road from the main road. The private road is gated and has signs to the fishery. The large fishery pond was man made many years ago and is fed by a stream with an outlet to a burn. There is a rocky boundary surrounding the pond. The pond was stocked with fish which were delivered to the site and kept in a holding tank for re-stocking the pond. Waders were required for this task. The pond shelves deeply from the shore and is of variable depth throughout due to silt carried through it from the inlet stream.
[3] The fishery pond and adjacent land are owned by Mr Ronald Cattanach who purchased the site about 2005. From 2005 until October 2014 Mr Cattanach ran the fishery as a business, Quarter Fishery Limited, with the assistance of his daughter, Gillian Cattanach. The fishery was open to the public all year round. Mr Cattanach also owned and still operates a separate building and landscape supplies business on a different site. Sometime in 2014 Gillian Cattanach opened a dog day care business on her father’s land, adjacent to the fishing pond and Ronald Cattanach decided to cease operating the fishery business.
[4] Mr Cattanach agreed to lease the fishery to Mark Sommerville whom he knew as a customer at the fishery. Mr Sommerville took over the fishery about 6 October 2014. A lease agreement, Crown production No 4, was drawn up by Miss Nina Bamrah, accountant, on Mr Sommerville’s instructions. The lease was signed on 5 December 2014 by Mr Cattanach as landlord and Mr Sommerville as tenant and provided for the lease of Quarter Fishery to Mr Sommerville. It was witnessed by Mr Sommerville’s fiancée, Erika McFarlane, who lent him £6,000 for the first payment. The lease was for a duration of 10 years with an annual rent of £6,000 and could be terminated on 3 months’ notice. On 9 December 2014, by e mail and telephone conversation Mr Sommerville instructed Miss Bamrah to set up a limited company with Mr Sommerville and Erika McFarlane as directors. They were also the only shareholders. There was some delay in Miss Bamrah acting on these instructions and the company, Quarter Fishery (Scotland) Ltd., was incorporated on 2 February 2015.
[5] Though no specific provisions were made in the lease, the lease of the fishery to Mr Sommerville included a wooden cabin on the site, a boat, a number of life rings situated round the perimeter of the fishing pond and miscellaneous minor pieces of equipment which did not include waders. Ronald Cattanach purchased the boat second hand about 2005. The boat is a double skinned vessel constructed of moulded glass reinforced plastic (GRP). Mr Cattanach used the boat for breaking ice on the pond. In 2010 the boat was damaged while he was breaking ice. Mr Cattanach repaired the boat himself with fibre glass resin. At the time the fishery was leased to Mark Sommerville the boat was poorly maintained and in poor condition.
[6] Prior to the transfer of the fishery to Mark Sommerville, Ronald Cattanach ‘walked the pond’ with Mr Sommerville and Peter Coyle and explained to them how the fishery was run. The main tasks were stocking the pond with fish, cleaning up, taking bookings, collecting money from the fishermen and selling them tea and coffee. Normally, the fishery did not require more than one person there to run it. It’s opening hours were 8.00 am until dusk in the winter, usually between 4.00 and 4.30 pm. The fishery was quiet during the winter months. Mr Cattanach offered night fishing in the summer and this was advertised on the fishery website. It was not popular and took place on no more three occasions during the nine years Mr Cattanach operated the fishery. He may have told Mark Sommerville and Peter Coyle about using the boat to break ice on the pond.
[7] A Risk Assessment, Crown production No 10, was prepared for Quarter Fishery when Mr Cattanach operated it. Mark Sommerville received a copy of this. The Risk Assessment did not cover breaking ice with the boat. No other Risk Assessment was prepared for the fishery.
[8] Mark Sommerville and Peter Coyle were friends for about 3 years prior to Mr Coyle’s death. Mr Coyle worked at the fishery on Mondays to Fridays from the time Mark Sommerville took it over, normally travelling to and from it by bus. He ran the fishery on these days. Mr Sommerville worked at the fishery on Saturdays and Sundays and ran it on these days.
[9] Peter Coyle was working at the fishery on 22 January 2015. The weather that day and for several preceding days was very cold, there was snow and ice on the ground at the fishery and the pond was frozen. There was ice on the pond for several days preceding 22 January 2015. Historical data from the ‘wunderground.com’ website indicates that temperatures in Motherwell itself from 17-24 January 2015 were for the most part below zero with a low of - 4 degrees celsius being recorded in the town of Motherwell on 20 January 2015. It is reasonable to assume temperatures were lower in the open countryside nearby.
[10] Mr Coyle was in and out of the cabin at Quarter Fishery during the day on 22 January and trying to break ice from the side of the pond with an oar. At some point during the day he took the boat out on the pond to break ice with it and the boat was holed. He then visited Gillian Cattanach at the adjacent dog crèche. He had waders on and told Miss Cattanach that he had holed the boat and thought he was going to drown when he was trying to break ice on the pond. Miss Cattanach told him he was ‘pissing in the wind’ because he was trying to break ice which was six days old and that he should not be wearing waders in the boat; if they filled with water they would tip him upside down. Mr Coyle thereafter tried to repair the hole in the boat with builder’s foam. Miss Cattanach left the Quarter Fishery site to deliver dogs home about 4.30 pm on 22 January 2015; she passed Mark Sommerville driving towards the fishery on the private access road.
[11] Mark Sommerville arrived at the fishery about 4.30 pm to drive Mr. Coyle home. It was nearly dark and still freezing. On his arrival Mr Coyle was out on the pond in the boat, about 30 to 40 metres from the shore in front of the cabin. The boat was stuck in ice. Part of the rope attached to the boat was still on shore. Mr Sommerville attached the end of the rope to the chassis of his car and revved the engine to try and bring the boat into shore. The rope broke. Water was rising up the sides of the boat and Mr Coyle was bailing water out of the boat with a pot which was previously in the cabin. Mr Coyle stood up in the boat and Mr Sommerville told him to sit down. Mr Coyle panicked and jumped out of the boat. He was wearing waders and no lifejacket. Mr Sommerville called for help to Hazel Howie, a member of the public who was walking her dog round the pond. She telephoned the emergency services and Mr Sommerville telephoned Ronald Cattanach for help. Mr Sommerville went into the pond with the intention of helping Mr. Coyle and was pulled back by Hazel Howie. He threw a life ring to Mr Coyle but it did not reach him. Mr Coyle splashed in the water for a short time and then became motionless with his face in the water and only the top of his head visible. Crown production No 3 is a disc and transcript of Miss Howie’s call to the emergency services.
[12] The Scottish Ambulance Service received an emergency call in respect of the incident at Quarter Fishery at 16.55 on 22 January 2015. A first response vehicle with one paramedic, Mr Alan Ritchie, was mobilised to attend at 17.58 and arrived at 17.10. Mr Coyle was already motionless with his face in the water when Mr Ritchie arrived. An ambulance with two paramedics was also mobilised to attend at 17.06 and arrived at Quarter Fishery at 17.17. Two fire appliances were mobilised at 17.01 and arrived at 17.13. The ice on the pond and the unknown depth of the water made it too dangerous for any of these emergency personnel to enter the water and attempt to recover Mr Coyle. A specialist Fire Service water rescue team at Clydesmill Fire Station, Cambuslang received an emergency call to the incident at 17.01, was mobilised at 17.02 and arrived at Quarter Fishery at 17.31. This team had a boat but it could not be used at the fishery because of the ice on the pond. Three firemen entered the fishery pond at 17.33 and swam out to Mr Coyle. The ice on the pond varied between two and six inches. The firemen had to break ice to reach Mr Coyle and removed him to an ambulance on shore at 17.38. There were no signs of life; resuscitation was attempted but Mr Coyle was pronounced dead by a doctor in attendance at 17.56.
[13] Access to Quarter Fishery via the private access road from Limekilnburn Road, Quarter, was difficult for all the emergency vehicles attending on 22 January 2015 as there was ice on the road. A specialist boat crew is based at Motherwell Community Fire Station which is nearer to Quarter Fishery than Clydesmill Fire Station, Cambuslang. Both crews at Motherwell Community Fire Station were mobilised to attend a fire in Wishaw at 16.58 on 22 January 2015; this included the boat crew personnel who were then unavailable to attend at Quarter Fishery. There was no delay in the boat crew from Cambuslang finding Quarter Fishery; one of the crew lived in the area and knew the location of the fishery. Some delay was caused by rush hour traffic at the time of day and icy road conditions.
[14] The boat was brought into shore by the fire service personnel. The boat had taken in water but it did not sink. The boat remained afloat at the edge of the fishery pond until removed on 10 February 2015 for examination by Environmental Health Officers from South Lanarkshire Council.
[15] A post mortem examination of Peter Coyle was carried out by Dr Gemma Kemp, Consultant Forensic Pathologist, on 30 January 2015. She found the cause of Mr Coyle’s death to be drowning. Toxicology analyses were negative for drugs and alcohol in his body. In her opinion Mr Coyle would have succumbed to the oxygen deprivation caused by water in his lungs within 5 to 7 minutes of entering the water and at most 12 to 14 minutes; his face entering the water would be a response to unconsciousness. Hypothermia, requiring a much longer period in the water for onset, played no part in his death.
NOTE
[1] This was an Inquiry into the death of Peter Paul Coyle who died at Quarter Fishery, Quarter, Lanarkshire, on 22 January 2015 aged 57 years. His death and it’s untimely manner have understandably caused his family much grief. He was the oldest of seven brothers and sisters, three of whom gave evidence in the course of the Inquiry. I offer my sympathy and condolences to Mr. Coyle’s family.
[2] This was a mandatory Fatal Accident Inquiry held in terms of section 6(a)(i) of the Act. The statutory responsibility for investigating and reporting the circumstances of Mr Coyle’s death under health and safety at work reporting authority regulations lay with South Lanarkshire Council. Ms Joanne Gardiner, Environmental Health Officer, undertook that investigation with colleagues and reported to the Procurator Fiscal. At the Inquiry the Crown was represented by Mrs Beadsworth, Procurator Fiscal Depute; Ms Janice Green, Advocate, represented Mr Mark Sommerville; Mr Murphy, Advocate, represented Ms Erica McFarlane; Mr Hamilton, Advocate, represented the Scottish Fire and Rescue Service and Ms Bryden, Solicitor, the Scottish Ambulance Service. The following witnesses gave evidence:
Mrs Anne Marie Miller, sister of the deceased;
Mr Arthur Muir Coyle, brother of the deceased;
Mr Samuel Coyle, brother of the deceased;
Mrs Tracey Coyle, sister-in-law of the deceased;
Ms Nina Bamrah, accountant;
Mr Ronald Cattanach, the owner of Quarter Fishery;
Ms Gillian Cattanach, daughter of Ronald Cattanach;
Ms Hazel Howie, a member of the public;
Mr Alan Ritchie, paramedic;
Ms Lynn Biggar, paramedic;
Mr Colin Hitchens, fire service crew manager,
Mr Mark Sommerville, lessee of Quarter Fishery;
Ms Erika McFarlane, fiancée of Mark Sommerville;
Dr Gemma Kemp, consultant forensic pathologist;
Ms Joanne Gardiner, environmental health officer;
Detective Constable Callum Lawrie;
Mr Ross Hunter, marine surveyor.
[3] There were a considerable number of Crown productions referred to in evidence and Joint Minutes agreeing evidence. Evidence was heard on 29 and 30 September, 6 and 7 October and 21 November and submissions on 22 November, all 2016. All parties made oral submissions and written submissions were lodged for the Crown and the Scottish Ambulance Service.
[4] I found all the witnesses generally credible and reliable, the passage of time sometimes affecting recollection and memories being prompted by contemporaneous statements. At the request of the Crown, I required to give warnings to two witnesses, Mark Sommerville and Erika McFarlane in terms of section 5(2) of the Act, that they were not compelled to answer any question tending to show guilt of any crime or offence. This had the effect of very limited evidence from Mr Sommerville and none from Miss McFarlane.
[5] There were a number of issues explored in some depth during the Inquiry. These included the basis upon which Mr Coyle was working at the fishery and whether he was employed there. The limited company, Quarter Fishery (Scotland) Ltd., set up by Ms Bamrah on Mr Sommerville’s instructions, was not incorporated until 2 February 2015, after Mr Coyle’s death and is therefore of no relevance to his employment status. The evidence from Mr Coyle’s relatives was that he was in receipt of Incapacity Benefit, that he was working at the fishery for Mark Sommerville and had more money to spend. Mrs Miller also said that her brother helped to set up the business and Mr Arthur Coyle that he helped his brother set up two mobile phones he had purchased from Tesco, one of which he used exclusively for Quarter Fishery. Mr Coyle’s sister-in-law, Tracey Coyle, spoke to Mr Coyle having received money from oil shares and to him showing her a bank mini-statement with a balance of £7,000 shortly before his death. When asked if she had heard of Peter Coyle, Miss Bamrah, the accountant who drafted the lease and set up a limited company, recalled Mr Sommerville telling her there was a silent partner who would come into the business as a non-executive director. Others who met Peter Coyle and Mark Sommerville at the fishery, Ronald and Gillian Cattanach and Hazel Howie, had differing impressions of their working relationship but in the end did not know what it was; they confirmed Mr Coyle was running the fishery on a day to day basis and Mr Sommerville was there less often.
[6] In a taped interview under caution with police and Joanne Gardiner, Environmental Health Officer, on 10 February 2015 Mark Sommerville said that he was in full time employment as area manager for a cleaning company. He and Mr Coyle took on the fishery and it was a working partnership. Mr Coyle managed it Monday to Friday and Mr Sommerville at week-ends. Mr Coyle did not want his name on any paperwork. They had no occupier’s or employer’s liability insurance and no paperwork, but intended to have an accountant and spreadsheets. He also said his fiancée of 12 years and mother of their children, Erika McFarlane, had loaned the £6,000 for the lease; she took no part in the running of the fishery but wanted to be a partner until she got her money back.
[7] Mr Sommerville said in evidence that he did not see any accounts for Quarter Fishery when he entered into the lease; he took Ronald Cattanach’s word that it made money. Between taking over the fishery on 6 October 2014 and Mr Coyle’s death on 22 January 2015 he and Mr Coyle were still finding their feet; the fishery was quiet as it was out of season for fishing. They used the money they collected for fishing during this period for fares, fuel and other expenses and neither took any wage.
[8] The Crown asked me to consider that Mr Sommerville and Ms McFarlane were partners in a business which employed Mr Coyle. I did not find Mr Sommerville’s statement in interview that Ms McFarlane was to be a partner until repaid her £6,000 and the description of Ms McFarlane as “partner” against her signature witnessing those of Mr Sommerville and Mr Cattanach on the lease an adequate evidential basis to infer she and Mr Sommerville had formed a business partnership running the fishery or that it employed Mr Coyle.
[9] I was also asked to consider that Mr Sommerville was Mr Coyle’s employer at the time of his death. Clearly Mr Coyle worked at the fishery and was working there at the time of his death. Miss Bamrah’s evidence that Mr Sommerville told her when giving instructions about the lease and the limited company that there was a silent partner who may become a non-executive director lends support to the credibility of Mr Sommerville’s statements in interview that he and Mr Coyle took on the fishery together. Other evidence about the extent of Mr Coyle’s involvement and responsibility on a day to day basis at the fishery is also supportive of that position. From Mrs Miller’s evidence Mr Coyle was also not without financial resources. On the basis of all the evidence available it was not possible for me to draw a conclusion on the balance of probabilities that Mr Coyle was employed at the fishery by Mark Sommerville.
[10] Mr Ronald Cattanach gave evidence about his use of the boat involved in the accident when he ran the fishery. He said it was a double skinned fibre glass rowing boat, purchased second hand in 2005 when he bought the fishery. It would not sink because it was double skinned. He used the boat rarely, to free fishermen’s lines caught on overhanging branches and to clear ice on the pond and create an area for fishing. Due to mild winters, the boat had not been used for this purpose for two years. Mr Cattanach broke ice on the pond by sitting in the boat and rocking it from side to side or he attached an outboard motor to the boat and circled it to create a wave. This task was only done between 8 am and 10 am following overnight freezing of the pond and his daughter was always present on shore; Gillian Cattanach confirmed this. Mr Cattanach wore a life jacket and never wore waders in the boat. When not in use the boat was pulled out of the water over the rocky shore by a rope kept attached and tied to a metal pole in front of the cabin. In 2010 the boat was damaged while he was breaking ice. Mr Cattanach repaired the boat himself with fibre glass resin. Prior to the transfer of the fishery to Mark Sommerville, Mr Cattanach ‘walked the pond’ with Mr Sommerville and Peter Coyle and explained to them how the fishery was run. Mr Cattanach could not remember if he told Mr Sommerville and Mr Coyle about using the boat to break ice but he could have.
[11] Expert evidence was led for the Crown from Mr Ross Hunter, a marine surveyor and naval architect of 30 years’ experience, regarding the condition of the boat. He produced a report (Crown production No 22) based on his examination of photographs of the boat taken by Joanne Gardiner on 10 and 24 February 2015 (Crown production No 3, photographs 0628-0645). It was Mr Hunter’s opinion that the boat was of a Dell Quay Dory type, typically a double skinned vessel constructed of moulded glass re-inforced plastic (GRP), usually measuring 11 x 22 feet though this boat was shorter. The boat was of a cathedral style with a W shaped hull. It had a platform for an outboard motor which was not fitted and rowlocks for oars which could be fitted in three different positions.
[12] The appearance of the boat was consistent with it having been acquired second hand some nine years before. The boat was poorly maintained; the hull was scuffed and abraded so badly in places the outer gel coating which forms a water barrier to the main structure was damaged and the underlying GRP exposed. The timber work and stringers were damaged, displaced and rotten in places. There was a physical hole in the hull where the stem moulds into the keel, seen in photograph 6640; it was difficult from photographs to be exact about the size of the hole, but it probably measured 150 x 60 millimetres. The hole breached the whole structure of the vessel and was visible from the inside of the boat to anyone in it. The hull of the boat was previously breached in the same area and repaired with a different colour of resin from the original laminate. The repair was poorly effected; there were voids in the laminate indicative of poor preparation and application of resin and mat. There was a similar poorly effected repair at the starboard side of the boat.
[13] Photographs 0628, 0646 and 0640 respectively showed expanding foam on the shore, on a lifejacket (recovered from the cabin) and in the boat near the damaged area. It was Mr Hunter’s opinion that an attempt was made to repair the hole in the boat with expanding foam. The use of expanding foam to repair a boat is wholly inappropriate. It is not strong enough, can deteriorate in water and does not stick well in damp conditions.
[14] It was Mr Hunter’s view that the general condition of the hull of the boat, damage to the gelcoat and the previous repairs indicated the boat had sustained damage over a considerable period of time. The cause of this could be attributed to using the boat to break ice and to the boat being dragged out of the water across the rocky shore on successive occasions. Rocking the boat from side to side to break ice risked damaging the boat. A vessel of this construction should not be used for breaking ice under any circumstances; contact with hard and sharp surfaces would break the gel coat and weaken the GRP laminate underneath to a point where it ruptured. The hull being holed was entirely consistent with the boat being used to break ice when this happened.
[15] Mr Hunter found it difficult to tell from the photographs whether the boat was of double skinned construction. However, the fact that it did not sink during the incident and remained afloat indicated it had an inherent buoyancy and would support it being of double skinned construction. It would still take in water from the hole in the hull.
[16] Mr Hunter examined two buoyancy aids and a life jacket recovered from the cabin at the fishery. In his view buoyancy aids would not assist a non-swimmer but a lifejacket would keep the person afloat. This had limited relevance in the case as Mr Coyle was not wearing a life jacket or buoyancy aid. Mr Hunter is a keen fisherman and has fished at many fisheries in Scotland. He has never seen anyone at a fishery wearing waders in a boat. The hazard is well known, of being dragged down if falling into the water and probably wholly submerged until the water pressure equalises. Even treading water would be difficult wearing waders.
[17] Mr Hunter’s evidence was clear that the boat should not have been used to break ice. It seems likely Mr Coyle acquired the idea of using the boat to break ice from Mr Cattanach. It was Gillian Cattanach ’s evidence that Mr Coyle told her on the day of his death that he had used the boat that day to break ice on the fishery and holed it and she had advised him this was useless given the depth of the ice and warned him against wearing waders in the boat. Mr Hunter’s evidence and the photographic evidence of the hole in the boat confirm it was holed. It was Mr Hunter’s opinion an attempt was made to repair the hole with foam; no-one else was at the fishery that day who could have done that and I have concluded Mr Coyle tried to repair the hole in the boat using builder’s foam. There is no doubt that Mr Coyle then took the boat out again that day on the fishery pond wearing no lifejacket and wearing waders. At the time he was seen in the boat by Mr Sommerville and Miss Howie, around 4.30 pm it was nearly dark and the ice on the pond from the fire service evidence varied between two and six inches thick. Why Mr Coyle decided to take the boat out in these conditions, whether to test the efficacy of the foam repair or break ice or some other reason, was not possible to ascertain in the Inquiry. There was no evidence of bookings for night fishing which would have been little short of extraordinary in the weather conditions.
[18] The evidence of the events which unfolded at the fishery after Mr. Sommerville’s arrival about 4.30 pm on 22 January 2015 came from Mr Sommerville and Miss Hazel Howie. Miss Howie’s evidence corroborated that of Mr. Sommerville. In particular, on her arrival at the fishery to walk her dog, when she saw Mr Coyle in the boat on the icy pond and Mr Sommerville attempting to pull it in by attaching the rope to the chassis of his car, there was no panic and no sign of distress from either; she exchanged some conversation with Mr Sommerville. This seems somewhat surprising in the circumstances but perhaps indicative of Mr Sommerville and Mr Coyle’s lack of appreciation of the dangers inherent in the situation. As she walked round the pond she saw Mr Coyle bailing water out of the boat. It was only on completion of her walk, as she started up the private road and Mr Sommerville called her back and asked her to telephone the emergency services that the panic and distress of both men were apparent; Mr Coyle was already in the water. It was Mr Sommerville’s evidence that Mr Coyle panicked and jumped out of the boat. It is apparent from the evidence that the boat, though it took in water, did not sink and remained afloat. It may have been unknown to Mr Coyle that the double skinned vessel had an inherent buoyancy.
[19] The Scottish Ambulance Service and the Scottish Fire and Rescue Service were represented at the Inquiry as there was some question of criticism of their response. From the evidence, no criticism could be made; help arrived as quickly as possible in the prevailing circumstances.to effect a difficult rescue. Miss Howie’s emergency call was made at 16.55. A transcript of the call, lasting some 12 minutes, was available. Near the outset of the call she gave the call handler a description of Mr Coyle in the water as being unresponsive and not moving. It is likely Mr Coyle had succumbed before there was any possibility of emergency services reaching him.
[20] The only Risk Assessment for Quarter Fishery was completed for Quarter Fishery (Scotland) Limited when Mr Cattanach ran the fishery; it did not contain any reference to breaking ice with a boat. Mr Sommerville had a copy of this Risk Assessment. With regard to a system of work, beyond replicating the tasks Mr Cattanach had indicated to Mr Sommerville and Mr Coyle were involved in running the fishery, it is apparent there was no recognisable system of work whatsoever at the fishery at the time of Mr Coyle’s death.