Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0173, written 17 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2014 |
|---|---|
| Reference | 2014-0173 |
| Deceased | Muriel Dawson |
| Coroner | Timothy Ratcliffe |
| Coroner area | West Yorkshire (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
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THIS REPORT IS BEING SENT TO:
1. Transport Research Laboratory
2. Vehicle Operator Services Agency
3. Optare
CORONER
I am Timothy Harvey Ratcliffe, Assistant Coroner for the Coroner Area of West
Yorkshire (Western).
CORONER’S LEGAL POWERS
I 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.
INVESTIGATION and INQUEST
On 6th November 2013 I commenced an investigation into the death of Muriel Dawson,
aged 90 years. The investigation concluded at the end of the inquest on 11th April 2014.
The conclusion of the inquest was a narrative verdict as follows:
“Muriel Dawson suffered an injury to her spine, fracturing her lumbar vertebrae L1/2, as
the result of her being thrown forward from her seat in an Optare 25/28 seater public
service vehicle travelling at under 20 miles per hour which braked suddenly to avoid the
possibility of contact with a car preparing to enter into the roadway from a private drive.
She had been seated in an aisle seat towards the front of the vehicle with nothing to
restrain her forward movement. No seat belt was fitted to her seat. Other passengers in
the bus were also thrown from their seats but did not suffer serious injury. The fracture
of her vertebrae and associated trauma led to her death shortly after the incident”,
the cause of death being 1(a) Complete fracture lumbar vertebra (L1/2) due to 1(b)
Osteoporosis.
CIRCUMSTANCES OF THE DEATH
These are as shown in the narrative conclusion in Box 3 above.
CORONER’S CONCERNS
During the course of the inquest 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) My findings were, as summarised in the narrative conclusion, that Muriel Dawson
was travelling on an Optare “hopper” type scheduled service bus (narrow model) and the
evidence to the Coroner’s court indicated that the profile of passengers on such a
vehicle would overwhelmingly be elderly. The evidence given was to the effect that the
design of the vehicle provides a compromise between safety and convenience as it
allows for standing passengers, seated passengers and provision for a wheelchair. The
design is such that the seat in which Mrs. Dawson was seated at the time of the incident
has no form of restraint should there be a violent forward motion exerted on passengers,
eg. by an emergency stop. The seat position (viewed from the front facing back) is on
the right hand side and is in the third row. It is the aisle seat of the first double seats, the
two rows in front being single seats on that side.
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(2) It is understood that these vehicles are type-approved and the operator has not
made modifications to them and thus the original design and approval of the vehicle is
universally that which is in regular use. Seat belts are not required to be fitted to any
seats.
(3) The evidence to the inquest was that this vehicle had to stop suddenly; the brakes
were correctly applied, but there was nothing to prevent Mrs. Dawson being thrown
forward and she lost her life as a result of hitting the front panel of the bus having slid
the remaining length of the vehicle. Her death was due to the impact with the vehicle
fracturing her spine.
(4) It appeared from evidence that, still consistent with convenience, disabled access
and gangway width, a floor to ceiling pole with horizontal bar, or some similar restraining
construction could have been applied to the area immediately in front of her seat.
(5) It is appreciated that the backs of seats, bars and similar elements of the interior of a
vehicle can cause injury in the event of a sudden stop, but I considered, based on the
evidence given, that some similar design feature of the vehicle as mentioned in (4)
above could, and probably would, have prevented Mrs. Dawson being thrown forward
for such distance and with such momentum as to cause her death.
(6) It appears from the evidence, albeit indirectly reported to the Coroner at the inquest,
that other operators have expressed concerns with the current design, but feel there is
nothing they can do in a type-approved vehicle. I am concerned that the type-approval
has given insufficient weight to the risk of death or serious injury.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. I,
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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner.
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.
17th April 2014 Signed:
Timothy Harvey Ratcliffe
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1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
6 , Head of International Vehicle Standards Zone 1/29-33 Department Department for Transport Great Minster House for Transport 33 Horseferry Road London SW1P 4DR . s Direct line: Miss Angela Plovie a HM Coroner's Office City Courts The Tyris Web Site: www.dft.gov.uk Bradford BD1 1LA Our Ref: MC/105825 Your Ref: THR/AP/B2117K-13 12 June 2014 Dear Miss Plovie | refer to your letter of 16 April following the inquest into the death of Ms Muriel Dawson. On conclusion of the inquest Her Majesty's Coroner made a finding that the design and location of the seat on which Ms Dawson was sitting on the bus contributed to her fall and ultimately to her death. | am replying as Head of International Vehicle Standards division, which has responsibility for road vehicle safety standards. | was grateful for the information provided in the Coroner's Regulation 28 Report and | have made further enquiries with the Driver and Vehicle Standards Agency (formerly the Vehicle & Operator Services Agency), which is an Executive Agency of the Department for Transport with responsibility for bus certification and roadworthiness in Great Britain. The subject vehicle (Registration Number YJ60 KFR) was first registered in October 2010 and is certified to carry a maximum of 25 seated passengers, 16 standees and 1 wheelchair user although these capacities would not apply simultaneously. To attain the maximum standing capacity all of the folding seats would need to be in the stowed position. In common with most buses currently operating in the UK, the vehicle on which Ms Dawson was travelling when she received her fatal injuries was approved to national regulations. These regulations specify the general safety items of the vehicles and include, for example emergency exits, lighting, and additional features to make it easier for disabled people, including wheelchair users to gain access. Amongst other provisions, they set requirements for additional hand holds, a minimum of 1 wheelchair space, together with a minimum of four priority seats for the disabled and elderly passengers. These priority seats have extra legroom and can be easily reached from the entrance of the vehicle. It is also important to recognise that incidents involving buses and coaches are rare. Travel by bus and coach is one of the safest modes of road transport in Great Britain, with the rate of killed and seriously injured passengers per mile travelled being approximately one third that of passenger cars. The Department is committed to improving safety for all bus passengers through the use of appropriate vehicle construction standards and ensuring the safe operation of vehicles. Vehicle manufacturers have some flexibility to install additional design features that benefit passengers providing they do not compromise the existing construction requirements. Our national regulations setting the minimum standards for new vehicles utilise a number of specifications that are harmonised with EU and wider international requirements. These standards are reviewed regularly by an International group of experts under the United Nations Economic Commission for Europe. The Department for Transport is an active participant in this group. The Coroner highlighted his concerns in Section 5 of the report. Within this | noted his suggestion that additional design features could have prevented Ms Dawson being thrown forward. Following the Coroner raising this matter with the Department, | intend to bring this to the attention of the bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT) technical group. My team will also raise the issue at the next meeting of the International technical group and consider whether it is appropriate to propose amending the minimum specifications for new vehicles (including those relating to the type approval) to help prevent this type of incident occurring in future. | am grateful for the Coroner raising this issue with the Department. Yours sincerely Head of International Vehicle Standards
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