Prevention of Future Deaths reports · 2014

Kenneth Paul

Regulation 28 report to prevent future deaths, reference 2014-0338, written 23 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Jul 2014
Reference2014-0338
DeceasedKenneth Paul
CoronerARW Forrest
Coroner areaSouth Lincolnshire
CategoryRoad (Highways Safety) 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.

A R W Forrest im, ercp, FRcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire
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. The Right Honorable John Hayes MP, Minister of State for Transport, Great

Minster House, 33 Horseferry Road, London SW1P 4DR

1 | CORONER Wale:

| am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire.

: id i
2 | 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.

3 | INVESTIGATION and INQUEST if

On 6" December 2013 | commenced an investigation into the death of Kenneth John
PAUL, age 61. The investigation concluded at the end of the inquest on 22™ July 2014.
The conclusion of the inquest was ACCIDENT

4 | CIRCUMSTANCES OF THE DEATH

Kenneth Paul was a man with a number of medical problems. In particular, he had
impairment of his peripheral vision and unsteadiness of his gait due to strokes affecting
the left side of his body. Shortly before 11am on the morning of 29" November 2013 he
left his home To as he did most days. His usual practice was to
walk diagonally across Hallgate to the side opposite his house on his way into the town
centre. a UPS driver, had just collected parcels from 1 Stukeley Road, at its
junction with Hallgate. He then reversed along Hallgate Road towards the town centre
for a distance of around 25 metres, intending to turn left into Church Road. During that
traverse, probably at the beginning of it,his vehicle travelled over Mr Paul. It is not

Za ;
known whether or not Mr Paul was upright or prone when the rear of BF crc

AR W Forrest iu, rrcp, FRcPath
GMC Number: 1333523
Her Majesty's Senior Coroner for South Lincolnshire
passed over him. Mr Paul sustained fatal injuries.

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. °

That the delivery vehicle, a Mercedes Sprinter that collided with Mr Paul, a vehicle with
no windows behind the driver's position, was not fitted with an audible warning device
that operated automatically when reverse gear was engaged and there is no legislative
requirement for such a device to be fitted to light commercial vehicles of this type.

ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and/or
your organisation 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 16" 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:

3. DAC Beachcroft Claims Ltd, 3 Hardman Street, Manchester, M3 3HF

4. Inspector [E”’ Floor, Witham House, The Pelham Centre, Canwick
Rd, Lincoln, Lincolnshire,_LN5 8HE

23” July 2014

AR W Forrest iw, rrcp, Frcpath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire
5. Cllr Nick Worth, Email: :

! 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.

ARW Forrest
H M Senior Coroner for South Lincolnshire

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

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