Mitchell Clifton

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Department of Transport (Vehicle Design Approval and Licencing)

The Ministerial Support Unit, Great Minster House, 33 Horseferry Road,
London, SW1P 4DR

CORONER

| am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South

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.

INVESTIGATION and INQUEST

On 5 October 2012 | commenced an investigation into the death of Mitchell Harvey
Clifton aged 7. The investigation concluded at the end of the inquest on 29 April
2014. The conclusion of the inquest was Road Traffic Collision.

CIRCUMSTANCES OF THE DEATH

Mitchell Clifton died at the scene of a road traffic collision at Landywood Lane,
Cheslyn Hay on 3 October 2012. He was travelling down the footpath on a scooter
and was struck by a van on an access way to a parking area. Neither Mitchell nor
the van driver was aware of each other's proximity until it was too late.

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. —

The van in question was a Mercedes Sprinter being used as a security van. As part
of the adaptations for it to be a security van the size of the driver's door window had
been reduced. The off-side wing mirror was standard. A reduction in the available
view to the off-side may have been a factor why the van driver did not spot Mitchell.
Perhaps you can kindly confirm that the design of this vehicle has been duly
approved and consider if any further adaptations regarding either the window or
mirror are appropriate.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 11 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

P| (Mother of the Deceased)

WR (Father of the Deceased)
GRR (Traffic Process Office — Staffordshire Police)

(Fentons Solicitors)

(Clyde & Co Solicitors)

Local Safeguarding Board)
EE (Clerk to Cheslyn Hay Parish Council)

| 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.

13 May 2014

Andrew A Haigh
HM Senior Coroner
Staffordshire (South)

: From the Parliamentary
> Under Secretary of State

Claire Perry MP
Department Great Minster House
for Transport 33 Horsetey Road

SW14P 4DR

Tel: 0300 330 3000
Andrew A Haigh Fax: 020.7944 4524
HM Senior Coroner E-Mail:
Staffordshire South Web site: www.gov.uk/dft
1 Staffordshire Place Our Ref: MC/106669
Stafford
ST16 2LP

05 SEP 2014

Adee /

Thank you for your Regulation 28 Report of 13" May to prevent future deaths,
setting out the findings of the inquest on the circumstances surrounding the
death of Mitchell Harvey Clifton, aged 7. The vehicle involved was a Mercedes
Sprinter which was being used as a security van, and you have asked the
Department to consider what action, if any, should be taken. This letter is my
response on behalf of the Department.

The circumstances of this tragic collision reinforce in my mind that we must not
be complacent about road safety, and both the Government and the
Department takes the safety of all road users very seriously. The Department
has published a Strategic Framework for Road Safety, which sets out general
safety measures.

My officials have established that the Mercedes Sprinter which is the subject
of your report has a European Whole Vehicle Type Approval (ECWVTA),
compliance with which serves as confirmation that the vehicle can be
registered in the UK.

There is no specific requirement in ECWVTA regarding the driver's field of view
to the side of a light commercial vehicle other than the ability to see a specific
area around the vehicle using the vehicle’s mirrors. However national approval
schemes for this category of vehicle produced in small numbers do require a
similar direct view to the side as that required for passenger cars.

Vehicles of the type involved in this incident are specially modified for their
industrial purpose after registration and there is no requirement for them to
undergo further inspection or approval following modification.

Once in use the vehicle is subject to the Road Vehicles (Construction & Use)
Regulations 1986 (C&U). Regulation 30 of C&U requires the driver to have a
view both of the road and traffic ahead of the vehicle, and of the mirrors; it does
not require a specific view to the side. Regulation 33 requires mirrors that
satisfy the technical requirements of European Directive 2003/97/EC or
UNECE Regulation 46, and that the driver is able to see the mirrors either
through the side window or through the area swept by the windscreen wipers.
The modifications to this vehicle did not affect adversely either of these
provisions.

You have asked me to consider whether adaptations to the window or the
mirror requirements are appropriate. As | have indicated, | take the matter of
vehicle safety seriously and have considered the national road casualty data
for light commercial vehicles to understand better the contribution of a reduced
view of the road to collisions, compared to other factors such as driver error or
inattention, and the potential for making regulation to improve the situation. The
circumstances of this case are tragic but | am not convinced that making
changes to the existing requirements would necessarily prevent such an
incident from happening again. On this basis | do not propose adaptations to
the current requirements.

| am grateful to you for raising this incident with me, and would appreciate you
conveying my condolences to Mitchell's family.

With FNQuiy ak’,

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, staffordshire
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Andrew A Haigh

HM Senior Coroner
Staffordshire (South) Coroner's
Jurisdiction

No 1 Staffordshire Place
Stafford

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Your ref: AAH

HoRSST/MS/RAS/C49

Dear Mr Haigh,

Re: Mitchell Clifton (Deceased)

Casualty Reduction Team
Wedgwood Building

Block A

Tipping Street

Stafford

ST16 2DH

Telephone 01785 276781
Fax 01785 895873

41 June 2014

| refer to your Regulation 28 Report, regarding the inquest into the death of Mitchell Clifton and

your comments concerning the location.

Following the accident involving Mitchell Clifton, the Co-operative introduced a number of
measures at the car park entrance including road humps, lane markings and a central hatched
area. A marked pedestrian route from Landywood Lane to the shop entrance was also

provided.

Some of the road markings have become worn and the Co-operative has agreed to renew
them. In addition, | have made arrangements for further markings to be provided on the
highway to compliment the markings provided on the car park. This will involve returning the
double yellow lines to the rear of the footway, extending the central hatching to the edge of the
carriageway and providing a give way marking/edge of carriageway marking at the junction of
the car park with Landywood Lane. These measures should highlight the presence of the Co-
operative entrance for both pedestrians and vehicles.

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| trust this is satisfactory. Please let me know if you require anything further.

Yours sincerely,

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