Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0144, written 31 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2014 |
|---|---|
| Reference | 2014-0144 |
| Deceased | Valerie Hancox |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford & Wrekin |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1,
Product Marketing Manager — Harvesting
AGCO Ltd
Abbey Park
Stoneleigh
Kenilworth
CV8 2TQ
7
CORONER
{am John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford &
Wrekin
CORONER’S LEGAL POWERS
| make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
P3
INVESTIGATION and INQUEST
On 19" September 2012 | opened an Inquest into the death of Valerie Anne HANCOX
aged 67 years. | adjourned that inquest under the then Coroners Act 1988 provisions to
await the conclusion of criminal Proceedings taken against the driver of a tractor which
had been towing a baler. Those criminal proceedings concluded at the Crown Court at
Shrewsbury on the 24°" February 2014 when the driver concerned was convicted of
causing death by careless driving and was sentenced. Following notification of the
conclusion of the criminal proceedings | was satisfied that the circumstances as to how
the deceased came by her death had been established and did not resume the inquest.
| have notified the Registrar accordingly. | was though notified of concerns by the
investigating officer as to the lack of markings on the baler which may have contributed
to the collision and having considered those concerns | consider that a formal report is
required with a view to preventing future deaths.
ay.
—|—
CIRCUMSTANCES OF THE DEATH
On the 14" September 2012 on the AS at Burlington, Shifnal, Shropshire a collision
occurred between 2 vehicles, a motor car driven by the husband of the deceased anda
Fendt tractor towing a Massey Ferguson 2190 baler. The collision occurred during the
hours of darkness and lighting would have been required. The tractor and baler driven
by the defendant pulled off the AS at Burlington where he intended to turn left off the
road and into a field to continue baling. As he pulled the large combination of
equipment off the road he was faced with 2 gates. The 1* nearest the road being open
but the 2” was closed and opening towards him. At this point the tractor was stopped
and the baler, in particular the chute, was left blocking the oncoming cars carriageway.
The car driver was completely unaware of the blockage. He did not see the bale chute
Prior to the collision and his wife died from the injuries sustained.
CORONER’S CONCERNS
During the course of the Investigation the evidence revealed matters giving rise to
concern. in my opinion there is a risk that future deaths will occur unless action is
taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
(1) The bale chute, when on the public highway, should not be in its lowered
position. However it appears to be standard farm practice to leave the bale
chute down when moving from one field to another along or to cross a public
highway.
(2) The bale chute was just short of 2 metres in iength and falls under the
legislation that, when on roads, it should be clearly marked. If it were over 2
metres then it would have to be lit.
(3) The bale chute had no markings and was painted matt grey. The
manufacturers state in their handbook that the chute should be stored in the
up position for travel on roads. This may explain why there is no marking but
relies on the driver adhering to that instruction.
(4) Given the potential for obstructing the highway, all the more so as the
manufacturer's instructions appear to be not followed, bale chutes should be
clearly marked so that anyone approaching side on, day or night, as the
deceased’s husband was, should be able to see it.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to Prevent future deaths and | believe your
organisation has the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 27" May 2014. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
1
t
8 COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
i. a: :..::-. of the deceased.
ii. Browne Jacobson solicitors for NFU mutual insurers of the deceased
DWF LLP solicitors for the defendant
Regional Director for the NFU West Midlands Region who may
ind it useful or of interest. i
| am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the coroner, at the time of
your response, about the release or the publication of your response by the Chief
Coroner. i
5 | |
31°* March 2014 J.P. Ellery
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