Prevention of Future Deaths reports · 2014

Arnold Soulsby

Regulation 28 report to prevent future deaths, reference 2014-0241, written 28 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report28 May 2014
Reference2014-0241
DeceasedArnold Soulsby
CoronerRobin Balmain
Coroner areaBlack Country
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

Smethwick Council House

High Street
we Smethwick
Robin J. Balmain ) 7G BY West er
H.M. SENIOR CORONER Os a) ones ~
- Tel: 0845 352 74
BLACK COUNTRY CORONER’S DISTRICT Fax: 0121 569 5384
(SANDWELL ¢ DUDLEY * WALSALL + WOLVERHAMPTON E-mail:
Metropolitan Borough Councils) Po
Date: 28 May 2014 Our Ref: RJB Your Ref:

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

The Secretary of State
Department of Transport,
Richmond House

79 Whitehall

London SW1A 2NL

4. CORONER

I Robin John Balmain am the Senior Coroner for the Black Country Coroners
Jurisdiction

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 6t February 2013 I commenced an investigation into the death of Arnold
SOULSBY.

The investigation concluded at the end of the inquest on 15't May 2014. The
conclusion of the inquest was that death was due to an accident.

4. CIRCUMSTANCES OF THE DEATH

Mr. Soulsby was a pedestrian crossing the road at traffic lights which were on
red in respect of traffic passing along the road which Mr. Soulsby wished to
cross. As he crossed in front of the lorry, the lights changed to green, the lorry
moved off without seeing Mr. Soulsby and he was knocked to the ground and
killed. The driver of the lorry was unable to see Mr. Soulsby because the
height of the bottom of the windscreen was above Mr. Soulsby’s height. The

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This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm

SENIOR CORONER
27 May 2014 Continuation

SL

vehicle did not have forward facing mirrors, nor was it required to do so in
view of its age.

CORONERS CONCERNS
The MATTERS OF CONCERN are as follows :-

I am concerned that the regulations that have been introduced requiring
lorries to have forward facing mirrors are not retrospective, hence there are a
large number of lorries on the road which do not have this facility. I have
conducted a number of inquests where the circumstances are similar and I
have previously drawn the attention of the department to this problem on (I
believe) two occasions, one prior to the 2007 Regulations providing for
forward facing mirrors and one thereafter.

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. I ask that the matter be looked at
again to see if provision can, even at this stage, be introduced for retrospective
fitting of forward facing mirrors to all lorries as I believe that deaths in these
circumstances are likely to continue.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of
the report, namely by 234 July 2014.

COPIES and PUBLICATIONS

I have sent a copy of my report to the Chief Coroner and to the following
interested Persons :

SENIOR CORONER
27 May 2014 Continuation

Tam 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.

RJ. Balmain
Senior Coroner

BAP

Responses

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.

Response from Department of Transport (PDF)
gue From the Parliamentary
q Under Secretary of State

Claire Perry MP

Department Great Minster House
for Transport 28 Horseferry Road
SW1P 4DR
Tel:
Robin J Balmain J.
H. M. Senior Coroner
Black Country Coroner's District Web site: www.gov.ukiaft
Smethwick Council House Our Ref: MC/108653
High Street Your Ref: RJB
Smethwick
West Midlands “4A SEP 2014
B66 3NT

ous Cw Eonar

| refer to your Regulation 28 Report to Prevent Future Deaths, sent to the
Secretary for State, dated 28 May following the inquest into the death of Arnold
Soulsby. On conclusion of the inquest you made a finding that the height of the
bottom of the windscreen, in relation to Mr Soulsby’s height, meant that the
lorry driver was unable to see him crossing the road at the traffic lights. The
lorry did not have retro-fitted forward facing mirrors, which may have prevented
the death. | am replying as Minster responsible for road vehicle safety.

The circumstances of this tragic collision reinforces 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.

Driver vision is an important factor in minimising collisions of large vehicles with
vulnerable road users and | have recently asked officials to prepare a
consultation which is specifically about retro-fitting forward facing (Class VI)
mirrors above the windscreen of heavy goods vehicles that were first registered
prior to 26 January 2007. These mirrors were required as standard fitment on
heavy goods vehicles first used after that date.

The consultation will explore the potential benefits and costs associated with
requiring retro-fit of these mirrors, and the practical engineering issues

associated with retro-fit on vehicles that were not designed to have these
mirrors fitted.

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

WH SAdre alc,

CLAIRE PERRY

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