Prevention of Future Deaths reports · 2014

Percy Gurton

Regulation 28 report to prevent future deaths, reference 2014-0546, written 22 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report22 Dec 2014
Reference2014-0546
DeceasedPercy Gurton
CoronerCaroline Beasley-Murray
Coroner areaEssex
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

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: 

Managing Director 
First Essex Buses 
Westbury 
CHELMSFORD 
CM13DL 

1 

CORONER 

I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 

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 12 August 2013 I commenced an investigation into the death of Percy William 
Gurton. The investigation concluded at the end of the inquest on 18 December 2014. 
The conclusion of the inquest was Accident The cause of death was 1a) bilateral 
pneumonia 1b) hypoxic brain injury and neck injuries 

4 

CIRCUMSTANCES OF THE DEATH 

Percy Gurton was a an elderly passenger on a bus which needed to make an 
emergency stop because a cyclist swerved in front of it. Mr Gurton was propelled 
forward off his seat and collided with the front of the inside of the bus. He sadly died 
from the injuries he sustained. There is no criticism whatsoever of the bus driver.  
CORONER’S CONCERNS 

5 

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) The bus is so designed that there is no barrier at least in front of the front seat on 
the right hand side where Mr Gurton was sitting at the time. 
ACTION SHOULD BE TAKEN 

6 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action. Consideration should be given to 
incorporating a barrier of some sort in front of the relevant seat. 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 15 February 2015. 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 and to the following Interested 
Persons –

(son), Kennedys Solicitors (First Essex Buses)  

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 

22 December 2014   Caroline Beasley-Murray 

2

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 First Essex Buses (PDF)
First (5

Westway
Chelmsford
Essex CM1 3AR

Tel:
Fax:

13 February 2015

Mrs Caroline Beasley-Murray

HM Senior Coroner for Essex
HM Coroners Court

A Block — Ground Floor

County Hall
Victoria Road
Chelmsford
CM1 1QH

Dear Mrs Beasley-Murray

Inquest into the Death of Mr P Gurton

| refer to your letter dated 22 December 2014 enclosing a Report to Prevent
Future Deaths pursuant to regulation 28 of the Coroners (Investigations)
Regulations 2013 ("the Report"). This Report was written following the conclusion
of the inquest into the death of Percy William Gurton.

First Essex has offered our sincere condolences to Mr Gurton’s family for their
loss. We have also offered support to the driver of the bus in question. | note
there is no criticism whatsoever of the actions of the bus driver which has been
of some comfort to him in this tragic event.

Your report records your opinion that action should be taken to prevent future
deaths and asks that First Essex gives consideration to incorporating a barrier of
some sort in front of the relevant seat.

Ul First Essex Buses Limited
Member Registered in England number 1961457

member ATOc Bamed Westway, Chelmsford, Essex, CM1 3AR

First

Westway
Chelmsford
Essex CM1 3AR

Tel:
Fax:

The tragic accident involving Mr Gurton was investigated fully by First Essex at
the time in accordance with its health and safety policies and procedures. In
addition, First Essex co-operated fully with relevant authorities on their
independent investigations including Essex Police.

Actions taken to date

Upon receipt of your letter dated 22 December 2014 and its report, we have since
met with the manufacturer of the relevant bus involved in this incident, Optare,
on 15 January 2015.

First is investigating with Optare the feasibility of retro-fitting some form of
containment onto this type of bus which may help to prevent future deaths in
circumstances such as those which occurred involving Mr Gurton. In principle, a
technical solution may include not only a barrier but other possibilities such as
handpoles. However, the risks associated with such a solution need to be
carefully evaluated, as there is a possibility that an unintended consequence of
any adaptation may be to actually increase the incidence and severity of
passenger injuries overall in the event of a collision or emergency braking. Adding
such fixtures to the interior therefore has to be considered carefully as it may
introduce additional risk of harm to passengers rather than reduce it.

Moreover, that response will subsequently also need to be assessed against and
take into account specific regulatory and licensing requirements on construction,
design and accessibility of public service vehicles and applicable industry and
regulatory guidelines and proposals (see below).

Technical, regulatory and industry issues

The bus in question is manufactured by Optare and is from their “Solo” range. It

was registered in 2002 and is some 13 years old. First Essex currently operates
24 of this type of vehicle with the same seating configuration but there are many
more in service throughout the UK with other bus operators (including other
FirstGroup bus operators).

The bus itself was purchased with the standard internal configuration at the time
as designed by the manufacturer, and as built to the “Certificate of Initial Fitness”
(COIF) standards and it complies with all legal requirements for operation. In the

| First Essex Buses Limited
‘Member Registered in England number 1961457

member ATOc Mitglied Westway, Chelmsford, Essex, CM1 3AR

First 5

Westway
Chelmsford
Essex CM1 3AR
Tel:
Fax:
first instance, issues of technical modification to buses should be referred to the
relevant manufacturer by the bus operator and this is what First Essex has done.

In addition, matters in relation to the construction, design and accessibility of
buses are subject to a number of specific regulations and licence conditions. Any
proposed technical modifications must therefore also be assessed against
regulatory and licensing requirements and developed with authorities to ensure
continued legal compliance with current legislation and guidance. Quite often,
the issue of containment is specific to priority seating areas and any change to
the configuration could potentially affect accessibility.

Moreover, it has become clear that the issue that you have raised is not an
isolated one and nor is it an issue specific to this type of bus or to First Essex.

The Department for Transport has flagged the issue of containment (primarily on
older buses) around priority seating and wheelchair/buggy spaces with industry
and manufacturer representatives (including the Confederation of Passenger
Transport of which FirstGroup is a member). All parties are actively engaging on
exploring the relevant issues with the aim of adopting an industry-wide approach.
The engagement recognises that the issue of containment for priority seats is not
unique to the Optare "Solo" bus type (First Essex itself operates a number of
different types of buses from multiple manufacturers as does every major bus
operator in the UK) or to any particular bus operator. This initiative is active and
ongoing so First Essex cannot as yet confirm what actions may result from this.
However, currently, it is anticipated that, a code of practice may potentially be
developed which would apply to all relevant bus operators in the UK. Naturally,
this aligned approach would much better address concerns of the type that you
have raised.

Actions proposed to be undertaken and timetable

Whilst First Essex is continuing discussions with Optare, the consideration of the
outcome of those discussions must necessarily take into account existing
regulatory and licensing requirements and any ongoing industry discussions on
the same issues. Any unilateral action which any single bus operator may take
would otherwise have piecemeal effect at best and may lead to unintended
consequences or non-compliance with new industry or Department for Transport
requirements.

Ul First Essex Buses Limited
Member Registered in England number 1961457

member AToOc Rialied Westway, Chelmsford, Essex, CM1 8AR

First >

Westway
Chelmsford
Essex CM1 3AR
Tel:
Fax;
At present, the Department for Transport's engagement with stakeholders on this
issue is Ongoing. There is no fixed timetable in respect of concluding that
engagement or the production of any outputs from it. However, should you wish,
| would be glad to keep you updated on developments from that.

ging
First Essex Buses Ltd

| First Essex Buses Limited

Registered in England number 1961457
cpt Sias, ATOC es
member = Mitglied Westway, Chelmsford, Essex, CM1 3AR

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