Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0223, written 9 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2014 |
|---|---|
| Reference | 2014-0223 |
| Deceased | Ernest Harper |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire & Luton |
| 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Philip Simpkins
Chief Executive
Bedford Borough Council
Borough Hall
Cauldwell Street
Bedford
MK42 9AP
1
CORONER
I am Ian Pears, Assistant Coroner, for the Coroner Area of Bedfordshire &
Luton
2
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.
3
INVESTIGATION and INQUEST
On 11th March 2014 the Senior Coroner commenced an Investigation into the
death of Ernest Charles Harper, aged 91. The Investigation concluded at the
end of the Inquest on 7th May 2014. The Conclusion of the Inquest was that Mr
Harper died as a result of [medical cause of death]:
Ia Acute Pulmonary Oedema
b Lower Respiratory Tract Infection
c Right Subdural and Subarachnoid Haemorrhage following a Fall
which injuries were caused as a result of him falling from a tailgate lift of a small
minibus, operated and forming part of Bedford Borough Council’s Accessible
Transport Fleet.
4
CIRCUMSTANCES OF THE DEATH
1
On the 20th February 2014 Mr Harper had been collected from his home address
via the Council’s accessible transport - a minibus – to visit the Goldington Day
Care Centre. His mobility was such that he used a zimmer frame and/or a trike.
Mr Harper was aged 91 at the time. On his return, with the aid of a Passenger
Transport Assistant, he manoeuvred onto the tailgate lift using his trike, but fell
to his side and off the tailgate, between a safety support and the back of the
vehicle.
5
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) That it was possible to fall between the safety barrier and the back of the
vehicle
(2) That details of a passenger’s health and/or mobility (for the purpose of risk
assessing the passenger’s safety when accessing and egressing the vehicle) is
dependant upon information supplied voluntarily by the passenger and/or his
family rather than by a formal assessment
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you,
as Chief Executive of Bedford Borough Council, have 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 4th July 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
I have sent a copy of my Report to:
The Chief Coroner.
I have also sent it to
or of interest.
(son of the deceased) who may find it useful
2
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.
9
Dated 9th May 2014
Ian Pears
Assistant Coroner
Bedfordshire & Luton
3
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.
Ret? git, | sfa/s 4 “VS rsp 1081p BEDFORD BOROUGH COUNCIL — Borough Charter greoited in 1166 STESTOR IN PEOPLE Chief Executive: P.J. Simpkins Your Ref: Mr | Pears — Assistant Coroner Our Ref: CEX/T7 [042 je] Bedfordshire & Luton HM Coroners Contact: Mr P Simpkins Office Direct Dial: The Court House Fax: Ampthill Bedfordshire MK45 2HX 23 June 2014 Dear Mr Pears Re: Inquest touching the death of Mr Ernest Charles HAPRER Inquest held on the 7 May 2014 at Coroners Court, Ampthill In response to the matters of concern raised in the Regulation 28 Report to Prevent Future Deaths dated 12 May 2014, | write to confirm actions taken by Bedford Borough Council. The matters of concern were described as follows: 1. That it was possible to fall between the safety barrier and the back of the vehicle. 2. That the detail of a passenger's health and/or mobility (for the purpose of risk assessing the passenger's safety when accessing and egressing the vehicle) is dependent upon information supplied voluntarily by the passenger and/or his family rather than by a formal assessment. Bedford Borough Council has taken the matters of concern very seriously and | am abie io respond to each point io describe the actions aiready taken and those in the process of being undertaken. Concern raised: 1. That it was possible to fall between the safety barrier and the back of the vehicle. Action Taken/Proposed: Devices have been retro- fitted to the doors on all Ford Transit vehicles, the type of vehicle the accident occurred on. This blocks the gaps between the back of the vehicle and the handrail. We are now talking to manufacturers and the Driver and Vehicle Standard Agency to see if there are any additional measures that can be introduced to further improve safety. In addition to this, through the Association of Transport Co-ordinating Officers, we are making other Local Authorities aware of our experiences. Concern raised: 1. That details of passengers health and/or mobility (for the purpose of risk assessing and egressing the vehicle) is dependent upon information supplied voluntarily by the passenger and/or his family rather than by former assessment. Action Taken/ Proposed: A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification. A newly redesigned Client Transport Referral Form has also been devised by the Transport Operations Group, in conjunction with Adult Services. The form which has been re-designed through consultation with our Occupational Therapists will focus on the person’s functional ability and will be used for initial transport requests, as well as requests for reinstatement of the transport service when there has been a break in service due to medical reasons. This new form will capture information taken from the person/family member and will help to determine whether the reinstatement of the previous transport arrangements are appropriate. The new proposed process also includes a requirement for a client specific risk assessment to be conducted by the Social Care Transport Team for every client who is not ambulant. The redesigned referral form will be introduced by 14 July 2014, A system has been produced and this will be implemented by 14 July 2014, to ensure that any information provided verbally by Day Centre staff to vehicle staff on arrival regarding the client is also provided in a written format. The written form includes guidance notes for staff with regard to what type of information must be relayed. If any concerns are noted during the day at a Day Centre, the day centre staff will verbally relay this information to the transport staff on arrival, backed up with the written form; copies of which will also be provided to the Social Workers and Social Care Transport Team. Bedford Borough Council has deleted historical information from its Routewise forms provided to staff working on the vehicle to make current information regarding passengers clearer to staff. This ensures that the driver and passenger assistant have the most current information on passengers. Bedford Borough Council have taken the actions outlined in this response and have also identified a range of proposed actions to prevent any further deaths through injury from falling from a vehicle. In conclusion, | would like to place on record the Council's sincere apologies for this unfortunate incident. Yours sincerely Philip Simpkins Chief Executive
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