Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0303, written 30 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2015 |
|---|---|
| Reference | 2015-0303 |
| Deceased | Giuseppina Incisivo |
| Coroner | Joseph Turner |
| Coroner area | West Sussex |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Andrew Jones MP, Parliamentary Under Secretary of State for Transport, Department for Transport, Great Minster House, 33 Horseferry Road, London SW1P 4DR 1 CORONER !am Joseph Turner, Assistant Coroner for the coroner area of West Sussex 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | amtniaae and INQUEST On 10 July 2014 the West Sussex Coroner commenced an investigation into the death of Giuseppina Incisivo, aged 79. The investigation concluded at the end of the inquest on 28 July 2015. The conclusion of the inquest was Road Traffic Collision. CIRCUMSTANCES OF THE DEATH Ms Incisivo was crossing North Street in the centre of Midhurst whilst the traffic was stop/start. She moved in front of a medium sized (27 gross tonnes) lorry, very close to the front, when the traffic suddenly moved off. She was run over and suffered catastrophic, traumatic injuries, dying at the scene within minutes. The driver's evidence was simply that he did not see her. Other witnesses suggested he could not have done so directly, and a reconstruction by the Sussex Police Forensic Collision Investigation Unit showed that Ms Incisivo would have come well under the height of the bottom of the windscreen. The vehicle had a front ‘blind spot’ mirror fitted and in good working order, but the evidence was that either a. The driver had visually swept the mirror (his evidence) but in the time delay before moving off Ms Incisivo had then moved in front of the vehicle, unobserved, or b. The size and shape of her image in the convex mirror, and lack of visual contrast between Ms Incisivo, a dark-haired, greying, lady around 5 feet tall, in light clothing, and the road surface, meant that she was insufficiently conspicuous (the Investigating Officer's expert opinion). In short, the driver, even using the mirror when she was in its reflection, would have found it very hard to distinguish Ms Incisivo. 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. — “130 July 2015 8 “| (1) That whilst the relevant EU Directives (2003/97/EC and 2005/27/EC) and associated legal requirements for some high-fronted goods vehicles require the fitting of a ‘front blind spot mirror’ (Class VI) of a certain size, shape and resulting view, the actual shape (convex) and size of such mirrors does not provide sufficient visibility of slow moving pedestrians (especially the elderly), or those not wearing highly visible clothing, especially when very close to the front of the vehicle. (2) That the lack of secondary ‘front obstruction’ warning systems, such as sensors which sound an audible alarm (similar to front parking sensors), or show a red/amber/green ‘safe to move’ light in the cab, or a forward facing camera with a screen in the cab, which would supplement the mirror means that over-reliance is placed on the mirror when, patently, it may not always serve its purpose. (3) That pedestrians, especially the elderly and children, whose height makes them difficult for drivers of such vehicles to observe may assume (wrongly) that a vehicle with a front ‘blind spot’ mirror ‘must’ see them when the reality is the opposite. (4) That, it seems, a general lack of awareness may persist of the risk posed when passing in front of such vehicles, and an assumption persist that because someone may be able to see the windscreen of the vehicle, that the driver ‘must’ be able to see them directly or indirectly. | am aware that other Coroners have reported similar concerns as regards older or other high fronted vehicles which need not have such mirrors. This is the second inquest | have heard into the death of an elderly person who, it seems, ‘assumed’ the driver would or must see them, directly or indirectly. “ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or your organisation, including the relevant vehicle agencies, have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 September 2015. | 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. | have sent a copy of my report to the Chief Coroner and to the following Interested Persons. eo Counsel), College Chambers, 19 Carlton Crescent, Southampton, Hants, SO15 2ET, representing the Incisivo family. NA Kennedy's Law LLP, 25 Fenchurch Avenue, London EC3M 5AD, representing the driver. | 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.
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.
AOR Great Minster House 33 Horseferry Road Department Ion Sr tanspon a Web site: www.gov.uk/dft Penelope A Schofield Senior Coroner Our Ref: MC/141198 Coroner's Office West Sussex Record Office 25 September 2015 Orchard Street Chichester West Sussex PO19 1DD Dow My Sokal) Thank you for your letter of 31 July, enclosing a Regulation 28 Report on the investigation into the death of Ms Giuseppina Incisivo. On conclusion of the inquest you made a finding that the size and the shape of the mirror gave insufficient visibility, and the lack of secondary ‘front obstruction’ warning systems, such as sensors or a forward facing camera with a screen in the cab, could have prevented the collision. Another factor is that pedestrians may be unaware that the driver cannot see them clearly, putting themselves at risk. | am replying as Head of International Vehicle Standards Division of the Department for Transport, which has responsibility for road vehicle safety standards. | would like to reassure you that the Department takes the safety of all road users very seriously and | will endeavour to explain the current legislation on vehicle construction matters and the steps being taken to address your concerns. As you are aware, the technical requirements for new vehicles are set at international level by both the United Nations (UN) and the European Union (EU). The UN Regulation 46 sets the requirements for mirrors and is very similar to EU Directive 2003/97/EC which you mention in your report. The requirement in both these sets of legislation is for the driver to be able to see a ground plane area, and in the case of the area directly in front of the vehicle manufacturers can decide whether to use a mirror or a camera to cover this. Their choice will depend on which products their customers require and their specific design as well as cost. In future it will be possible for manufacturers to replace all mirrors with cameras. Engineers in my team are working at both national and international level to improve the safety of HGVs. Consideration is being given in EU Working Groups to improving direct and indirect vision for drivers, which we anticipate will help to prevent future collisions with vulnerable road users. We are also working closely with Transport for London (TfL) on safety measures. Research by the Transport Research Laboratory for TfL on a range of technologies which can be fitted to HGVs to detect pedestrians and cyclists is currently being peer reviewed, and this could form the basis of advice to manufacturers and operators, in advance of changes to approval regulations for new vehicles being agreed in the EU. Although sensor technology is available to identify objects around a vehicle, the technology has not yet developed sufficiently to distinguish between people and street furniture or other vehicles. As the technology improves this may offer a solution in future. You have correctly identified that there is also a role for pedestrians in understanding when it is safe to cross in front of a vehicle. You may be aware that adult (60+) pedestrian casualties have shown a steady decline in recent years. However, in 2014, the latest year for which statistics are available, there were still 191 fatalities and we are not complacent about this issue. The Department issued revised guidance in January 2014 aimed mainly at local traffic authorities who are responsible for setting speed limits on local roads. It has been designed to help explain to everyone why and how local speed limits are determined. This guidance was revised following full public consultation in summer 2012. Pedestrian walking speeds and crossing timings are matters for guidance rather than legislation, and the Department will be considering how best to update the guidance. | can confirm that we intend to produce a new chapter of the Traffic Signs Manual on traffic lights and pedestrian crossings, bringing together and updating existing advice. Unfortunately we are unable to give a precise date for publication. The Department is supporting the Living Streets organisation, who are campaigning on the safety of older pedestrians and are the UK charity for everyday walking; | attach their website link htip://www.livingstreéts.org.uk/make-a-change/take-action-with-us/crossings | will also bring this case to the attention of road safety colleagues in the Department to find out what more can be done, to raise awareness of drivers and pedestrians of the risks when they are in close proximity to one another. | am grateful to you for raising this incident with me, and would appreciate you conveying my condolences to Ms Incisivo’s family. Head of International Vehicle Standards Division
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