Fatal Accident Inquiry into the death of Ciaran James Williamson

The following is a summary of the main findings in the Determination by Sheriff Linda Ruxton following a Fatal Accident Inquiry held in Glasgow into the circumstances of the death of Ciaran James Williamson, aged eight, who was killed on 16 May 2015 when he was crushed by a gravestone in a Glasgow cemetery.

A fatal accident inquiry into the death of Ciaran Williamson, who died when he was crushed by a headstone which fell on him in Craigton Cemetery, Berrysknowe Road, Glasgow, has found that the event was a tragic accident which might have been avoided if certain safety precautions had been taken.

Sheriff Ruxton has recommended that consideration be given to drawing up guidance on memorial safety and stability testing for local authorities in Scotland and that the existing industry guidance be re-visited with a view to producing separate guidance on the inspection of traditional memorials and, in particular, those whose centres of gravity are shifting from vertical.

The sheriff further recommended that Glasgow City Council re-consider their recent guidance to take account of these matters.

The Inquiry heard that the cause of death was head and neck injury consistent with blunt force trauma when a large memorial stone erected in the early 1920s in memory of Alexander and Elizabeth Ross (“the Ross memorial”) fell and crushed Ciaran. He was struck on the head and body by the top (pediment) section of the memorial as it fell to the ground. The memorial stone was about seven-feet-high and weighed almost two-and-a-half tons. Death was instantaneous and painless.

The cause of the accident was the playful activity of children on the Ross memorial during which sufficient lateral force was generated at the top part of the memorial to cause it to wobble and topple. As the memorial started to wobble, three of the children who had been queuing for their turn to climb the memorial stepped onto the base of the stone and grabbed hold of the inscription plate in an attempt to stop the gravestone from falling. Although this would inadvertently have added a further destabilising force, by that time the memorial was collapsing and nothing would have prevented its fall.

When he was struck, Ciaran had been standing at the base of the memorial a little distance away. The other boys jumped out of the way but Ciaran was struck by the pediment. It also seemed likely that at some point Ciaran fell as he was trying to get out of the way of the falling memorial.

At the time of the accident, the memorial was leaning from vertical at an angle of 6.2-6.5 degrees. This lean had been progressing for some time and was caused by the encroachment of roots from an adjacent tree – these roots had infiltrated and undermined the foundations of the gravestone and had caused the base of the memorial to lift. The gravestone was leaning away from the perimeter wall towards the ground. Its centre of gravity had shifted. It had a pediment on top which overhung the main memorial plate and added to its instability once leaning. The structure’s tipping point – the point when it would overturn spontaneously – was an angle of 7.6.degrees. It was not dowelled or otherwise secured.

The Inquiry heard that Ciaran had been completing his homework when four friends, boys then aged between 7 and 10, called round for him to go out to play. 

During the course of preliminary hearings, it was decided that the experience of giving evidence and being asked to re-live the circumstances of the accident might have damaging consequences for the boys. Instead, their evidence was admitted by means of video recordings of their police interviews, which took place in April 2016, some 11 months after the accident.

Sheriff Ruxton said that she was satisfied from the boys’ combined accounts that certain facts had been established. The boys had entered Craigton Cemetery through a large hole in the perimeter wall which was situated directly opposite the flats at Moss Heights where Ciaran and some of his friends lived.

At the time of the accident, the children were playing a game which they had played before. It involved climbing on to the Ross memorial, pushing off from the top of the memorial to the perimeter wall and from there grabbing the branch of an adjacent tree and swinging to the ground. The children also used the cemetery as a short-cut.

Although the evidence showed that children played in the cemetery, there was no evidence before the Inquiry that Glasgow City Council were aware of these activities.

Sheriff Ruxton said: “I have no hesitation in accepting that this was a tragic accident. There was no suggestion that there had been a deliberate attempt by any of the boys to push over or destabilise the memorial. I am satisfied that, however perilous their activities, they were simply playing and had not appreciated the dangers involved.”

The Inquiry heard a great deal of evidence about the various sources of industry guidance available to local authorities on the subject of the safe management of cemeteries. A central feature of that guidance is a robust system of memorial inspection to ensure the safety of members of the public and employees working there.

Glasgow City Council had stopped carrying out routine memorial inspections several years before the accident. At the time of the accident, there was no organised, active or adequate system of inspection of memorials in progress. No stability checks had been carried out in Craigton Cemetery and, in particular, on the Ross memorial as part of any structured system of inspection.

Sheriff Ruxton was satisfied that had such an inspection been carried out on the Ross memorial, it would have failed and been declared unsafe. Urgent measures would have been taken within 24 hours to cordon it off or otherwise make it safe, probably by laying it flat.

Therefore, Sheriff Ruxton determined that a routine inspection of the Ross memorial was a reasonable precaution whereby Ciaran’s death and the accident that resulted in his death might have been avoided. She also concluded that the absence of an active system of memorial inspection was a defect in Glasgow City Council’s system of working which contributed to Ciaran’s death and the accident which resulted in his death.

The sheriff also found that repairing the hole in the wall was a reasonable precaution whereby the accident and Ciaran’s death might have been avoided.

In the course of the Inquiry, stark divergence of expert opinion and fundamentally different interpretations of the industry guidance on the stability testing of memorials became apparent. These differences demonstrated the need to clarify industry guidance as to the appropriate testing procedure to be adopted for large, traditional, multi-layered memorials.

In particular, the guidance should make clear whether and how hand-testing should be carried out. Furthermore it should be made clear that the industry-recognised 25 kilogramme pressure test is not appropriate for such structures but applies only to lawn memorials or other small memorials.

Glasgow City Council’s new 2015 guidance, which was based on the accepted industry advice that was available at the time, remains open to misinterpretation and has perpetuated the confusion between the testing criteria for larger memorials and lawn memorials. Sheriff Ruxton explained that the 25 kilogramme test has been replaced by a ‘minimum force’ test which itself seems vague and still does not address the problems associated with large memorials which are moving from a vertical position.   

Sheriff Ruxton identified the need for the industry to produce guidance on the testing of large, heavy memorials which, like the Ross memorial, are leaning. Their centres of gravity are shifting: such memorials, if not otherwise secured or dowelled, will continue to move (however slowly) until they overturn and fall to the ground. It is not a question of whether but when they will do so. Due to their size and weight, these memorials present a particular hazard having the potential to cause serious or fatal injury.

These were matters which the sheriff considered had significant implications for the safety of the public who visit cemeteries and all who work there. Accordingly, she made a number of recommendations.

  • That separate Scottish guidance on memorial safety in cemeteries be drawn up by the Scottish Government for use by local authorities throughout Scotland. Such guidance should include a category of advice on how to inspect large, traditional monuments such as the Ross memorial, as distinct from lawn memorials and other smaller structures. Given the potential danger posed by large leaning memorials, these should be given special attention and clear guidance produced as to the procedures to be adopted in order to carryout meaningful stability checks to assess whether there is concerning movement associated with such structures.
  • That Glasgow City Council re-consider their recent 2015 guidance on stability inspection to take account of the issues raised in the Inquiry.
  •  That consideration be given by the relevant agencies and associations that their existing guidance on memorial safety and stability testing be re-visited with a view to producing separate guidance on the inspection of traditional memorials and, in particular, those whose centres of gravity are shifting from the vertical.  

Since Ciaran’s accident, Glasgow City Council have re-introduced a structured system for the inspection of memorials. They have completed comprehensive stability inspection of all cemeteries throughout Glasgow, including Craigton Cemetery.

In conclusion, the sheriff expressed her appreciation and gratitude to those who represented the various parties to the proceedings.

Finally, Sheriff Ruxton added: “I would like to express my deepest condolences to Ciaran’s family and in particular to his mother, Ms Stephanie Griffin, his father, Mr Ryan Williamson and his step-father, Mr Thomas McGhee. It was a harrowing experience for them to listen to parts of the evidence in this Inquiry and they did so with great fortitude and dignity. These were profoundly sad proceedings inquiring into the tragic death of Ciaran Williamson, a little boy of eight whose whole life lay before him.” 

The full determination can be accessed via the Scottish Courts and Tribunals Service website. 

Notes to editors

This summary is provided to assist in understanding the sheriff’s determination. It does not form part of the reasons for the decision. The full determination is the only authoritative document.