Prevention of Future Deaths reports · 2014

Neil Blood

Regulation 28 report to prevent future deaths, reference 2014-0183, written 4 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Feb 2014
Reference2014-0183
DeceasedNeil Blood
CoronerIan Smith
Coroner areaStoke-on-Trent & North Staffordshire
CategoryOther related deaths · Product related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

ANNEXA

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1.
President
Shimano Inc
3-77 Oimatsu-cho
Sakai-ku
Sakai City
Osaka 590-8577
Japan
2. Rt Hon Patrick McLoughlin MP
Secretary State for Transport
Department of Transport
Great Minster House
33 Horseferry Road
London
SW1P 4DR

CORONER

lam lan Smith, senior coroner/area coroner/assistant coroner, for the coroner area of
Stoke-on-Trent & North Staffordshire.

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.
[HYPERLINKS]

INVESTIGATION and INQUEST

On 12 August 2013 | commenced an investigation into the death of Neil Andrew Blood,
aged 42. The investigation concluded at the end of the inquest on 4 February 2014. The
conclusion of the inquest was Accidental Death. The cause of death was given as 1a
Chest injuries.

CIRCUMSTANCES OF THE DEATH

In July 2013 the deceased and various members of his family went to Jersey on holiday.
He had purchased a new pedal cycle shortly before the holiday and took it with him. He
had done some cycling on the island. On 31* July 2013 he went for a ride on his bicycle
accompanied by a family member. Shortly before 1.15pm they were cycling along the
pavement adjacent to a road known as Commercial Building near to South Pier
Shipyard, St Helier when the deceased appeared to look behind him briefly and then
almost immediately afterwards his bicycle wobbled as he seemed to lose control, his
feet becoming stuck in the cleats of the bicycle’s pedals. The deceased was then
observed to fall to its offside, off the pavement and under the side of a passing van and
under the nearside rear wheel of the van. The deceased was treated promptly by local

first aiders and paramedics but died of his injuries shortly afterwards at the General
Hospital, St Helier, Jersey.

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. To Shimano Inc: | can do no better than to repeat the comments of my colleague,
the Deputy Viscount of the Royal Court of Jersey, made in his letter of 30 January
2014 (copy attached).

2. To Department of Transport (UK): What oversight, control or legislation governs the
supply of pedal cycle cleats and shoes, and what consideration has been given to
the potential risks and dangers involved and what warnings should be supplied at
the time of purchase?

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you or your
organisation 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,
namely by 30 June 2014. 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.

8 | COPIES and PUBLICATION
| have sent a copy of my report to the following recipients:-
1. Chief Coroner, Regulation 28 Reports, Chief Coroner's Office, 11° Floor Thomas
More Building, Royal Courts of Justice, The Strand, London, WC2A 2LL
2. EEE Vico. of the deceased).

| 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.

oo 4
dienes Majer URZoA ,

2

Related reports

Other reports by Ian Smith

See all →

More reports categorised “Other related deaths”

See all →

Track Product related deaths

See every Prevention of Future Deaths report matching Product related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.