Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0329, written 8 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jul 2014 |
|---|---|
| Reference | 2014-0329 |
| Deceased | Muriel Naylor |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT iS BEING SENT TO: 1. Department of Transport 2. Fentons 3. Backhouse Jones 4. HEB vosa CORONER 1am Senior Coroner for the coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 an and 29 of the Coroners (Investigations) Regulations 2013 qd reguy tions 2 INVESTIGATION and INQUEST On the 6" December 2011 | commenced an investigation into the death of Muriel Naylor for w of death had been given as being that of 1a) Fracture and Dislocation of first and second cenom the ca and at an inquest hearing at the Oldham Magistrates Court on the 17" June 2014, witha Jur vical y, rt bree conclusion was made ‘on the 19" November 2011, the bus on which Mrs Naylor was trayey ne Forts, rae action an emergency stop to avoid a collision with another vehicle. This sudden braking Causey ne 9 hog re be projected forward from a designated priority seat into the wheelchair / tip-up bay. The tr. rs Naviorto she sustained as a result of the impact caused her death which could have possibly been Preventntic injury other safety measure had been fitted which may have restricted Mrs Naylor’s movement. Mrs ented | so, y was confirmed at The Royal Oldham Hospital on the 19" November 2011 at 5-45pm. Naylor me CIRCUMSTANCES OF DEATH As above CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In Ny opin: a risk that future deaths will occur unless action is taken. In the circumstances it is my Stature t Bre j report to you. “tory duty to The MATTERS OF CONCERN are as follows:- 1. The vehicle in question is double deck Alexander Dennis Enviro 400 owned b y Stagecog least 900 are still in use within the UK. ch of Which at i. The vehicle is required to have a minimum of 4 priority seats to allow access for disabie that can be accessed from the flat floor area of the vehicle, thus avoiding the PaSSenger hay. 2nd negotiate unnecessary steps. A priority seat has to be as close as practical to the Priovit Vin, to and such seats must have a clear area in front of the seat to allow passengers feet ty y aang least 230mm before the start of a minimum clear space of 1300mm to facilitate the . Pp aCeg a aTrage t 0 wheelchair users (Public Service Vehicles Accessibility Regulations 2000). ill. Regulations make no mandate for a screen / barrier to be present in front of such a priority seat. IV. _ As standing passengers are carried on this vehicle, seat belts are not mandatory although this would not preclude the fitment of a seat belt as an option. However, a seat belt could only be fitted if there was sufficient anchorage and the seat itself would have to undergo a ‘pull’ test. The priority seat in question would not, it is believed, comply with the ‘pull’ test. V. Notwithstanding the fact that Mrs Naylor was a very fit and active 79 year old. She was propelled across a void of a 184cm before sustaining injuries which crushed her upper spinal cord causing immediate unconsciousness and paralysis. Vl. Given that priority seating is intended to protect the most vulnerable users of the service, it is of significant concern that the risk is accentuated by the lack of any restraint. ACTION SHOULD BE TAKEN Action should be taken to consider legislation that would prevent fatalities occurring in similar circumstances. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 1° September 2014. |, 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 namely - 1.Department of Transport 2.Fentons 3.Backhouse Jones vos. 5.Chief Coroner 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 from. 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. Date: 08/07/2014 Signed
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.
4’a Head ofCrash Injury Mitigation Branch ID ePartment International Vehicle Standards Division Zone 1/29-33 f r Tr DepartmentforTransport F—’ Great MinsterHouse 33 Horseferry Road London SW1P4DR Mr S Nelson Direct line: Her Majesty’s Coroner Fax: HM Coroner’s Court GTN: The Phoenix Centre L/Cpl Stephen Shaw MC Way Web Site: www.dft.gov.uk Heywood Our Ref: OLI0 1 LR Your Ref: 18 Nov2014 Dear Mr Nelson Thank you for your letter dated 11 November, which referred to your inquest into the death of Mrs Muriel Naylor. On conclusion of the inquest you made a finding that the design and location of the seat on which Mrs Naylor was sitting on the bus contributed to her fall and ultimately to her death. I am replying as head of the Crash Injury Mitigation branch within International Vehicle Standards division, which has policy responsibility for road vehicle safety standards. I was grateful for the information provided in your Regulation 28 Report and I have made further enquiries with the Driver and Vehicle Licensing 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 MXO9 AUK) was first registered in May 2009 and is certified to carry a maximum of 33 seated passengers, 14 standees and 1 wheelchair user on the lower deck, although these capacities would not apply simultaneously. In common with most buses operating in the UK, the vehicle on which Mrs Naylor was travelling when she received her fatal injuries was approved to national regulations. These regulations specify 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 handholds, a minimum of 1 wheelchair space, together with a minimum of 4 priority seats for 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 numb r of specifications that are harmonised with the European Union 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. I have already brought this issue to the attention of the bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT), and the Confederation of Passenger Transport (CPT) who represent the bus & coach operating industry. We have a tripartite meeting scheduled this month, at which we will be encouraging them to adopt additional safety features for these seating positions where it is possible. I also intend to raise this issue within the International technical group responsible forthe pan-European construction requirements to explore whether it is appropriate to amend the minimum specification for new vehicles to reduce the risk of similar incidents in future, and to determine whether there is international support for such a move. I hope you find this information helpful and are assured that the Department is taking appropriate action to respond to your concerns. Yours sincerely Head of Crash Injury Mitigation International Vehicle Standards Division
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