Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0012, written 18 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2016 |
|---|---|
| Reference | 2016-0012 |
| Deceased | Norah Fairhurst |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| 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: 1. The Rt Hon Patrick McLoughlin MP, Secretary of State for Transport 1 | CORONER I am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West 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 the 14" August 2015 I commenced an investigation into the death of Norah Mary Fairhurst, born on the 21% December 1952. The investigation concluded at the end of the inquest on the 5” January 2016. The Medical Cause of Death was 1a Multiple Injuries. The conclusion of the Inquest was Road Traffic Collision. 4 | CIRCUMSTANCES OF THE DEATH At around 14.47 hours on Saturday the 8°" August 2015 a Volvo FRH, Articulated Lorry, registration number a is being driven along Gerard Street on the A58 in Ashton in Makerfield, Wigan by . The vehicle is a left hand drive model which was registered in the UK. As the lorry approached a puffin crossing on Gerard street, the traffic lights changed to red and ; slowed down in accordance with the requirements of the red light. At this time Mrs Fairhurst crossed Gerard street a considerable distance from the puffin crossing at a diagonal angle, approaching the vehicle from the right hand side. As the lights changed to green J continued on his journey and the vehicle collided with Mrs Fairhurst, who at this point was directly in front of the vehicle, causing her multiple injuries which led to her death. 5 RONER‘ ERNS 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. During the inquest evidence was heard that: i. The heavy goods vehicle involved in the collision was in good working condition and had visibility mirrors in accordance with legislation. [I diving was in accordance with that of a reasonable and competent driver. At the time of the collision Mrs Fairhurst had crossed the road in such a manner that she would not have been visible to lM prior to the collision, either in any of the mirrors of the vehicle, or from his direct line of vision from the vehicle. ii. I heard evidence that there are many blind spots on a large goods vehicle, but one of the most concerning blind spots is in front of the vehicle. Due to the size and height of a large goods vehicle a driver is unable to see directly in front of the vehicle and so if a pedestrian or cyclist were in front of the vehicle, the driver would not see them. ii. I heard evidence that in 2008 legislation came into force that required any large goods vehicle registered after a certain date to have a Class VI mirror, also known as a cyclops mirror, fitted to the front of the vehicle so that the driver would be able to see directly in front of the vehicle. If used appropriately this mirror could therefore identify anyone, or anything, in front of the vehicle. The legislation however, did not provide for the fitting of such mirrors to large good vehicles registered before 2008. Vv. I have since been made aware that pursuant to Directive 2007/97/EC, it became mandatory for all goods vehicle manufactured over 7500 tonnes to have a Class VI mirror fitted to the front. I understand however, that it was agreed and is stated in the Heavy Goods Inspectorate Manual that ‘vehicles registered from the 26 January 2007 but before 26 January 2008 in excess of 7500kg may not have a front mirror’. Accordingly, any vehicle registered from the 26" January 2008 must have a front mirror fitted, but those registered before do not require one. v. The large goods vehicle involved in the collision with Mrs Fairhurst was registered on a date before the 26" January 2008 and as a result did not have a Class VI front mirror attached to the vehicle. EM stated in evidence that this would have assisted him in seeing something directly in front of his vehicle. vi. I heard evidence from Fs the Forensic Collision Reconstruction Officer, that there have been a number of fatal incidents in similar circumstances as occurred in Mrs Fairhurst’s death, and that if used appropriately the Class VI mirror would identify persons in front of a vehicle and could therefore prevent a_collision and serious or fatal injury occurring to pedestrians or cyclists. 2. Ihave concerns with regard to the following: i. Due to the lack of Class VI front mirrors on large goods vehicles registered before the 26" January 2008, future deaths could occur involving pedestrians or cyclists who are positioned directly in front of such a vehicle due to the fact they cannot be seen by the driver of the large goods vehicle. ii. I therefore request that a review be conducted of the regulations regarding the use of Class VI mirrors, designed for pedestrian and cyclist activity at the front of large goods vehicles, in order to consider the requirement to use such mirrors on large goods vehicles registered prior to the 26" January 2008. 9 Dated Signed ” ? : 18" January 2016 Rachael C Griffin ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 14"" March 2016. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) «Solicitor, Slater & Gordon Lawyers on behalf of J GE. Mrs Fairhurst’s husband (2) EE Solicitor, Kennedys Law LLP on behalf of ii I have also sent this report to the Forensic Collision Reconstruction Unit of Greater Manchester Police who may find it useful or of interest. 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.
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.
ASR Great Minster House 33 Horseferry Road Department SWIP4DR for Transport Tel: 020 7944 2080 E-Mail: ian.yarnold@dft.gsi.gov.uk Web site: www.gov.uk/dft Rachael C Griffin HM Assistant Coroner Our Ref: ID 154398 Manchester West HM Coroner’s Court 13 May 2013 Paderborn House Howell Croft North Bolton BL1 1QY Dear Ms Griffin Thank you for your letter of 18 January addressed to the Secretary of State, enclosing a Regulation 28 Report on the investigation into the death of Mrs Norah Mary Fairhurst. The circumstances of this accident are that Mrs Fairhurst had crossed the road in such a manner that she would not have been visible to the lorry driver. On conclusion of the inquest you made a finding that future deaths could occur if pedestrians and cyclists are located directly in front of a large goods vehicle which is exempt from the requirement to have a Class VI mirror. You have requested that a review be carried out on the regulations to consider the retro-fitting of a Class VI mirror to currently exempt vehicles. | am replying as Head of the International Vehicle Standards Division of the Department for Transport (DfT) as this division has responsibility for road vehicle safety standards. Directive 2003/97/EC relates to the fitting of indirect vision devices, including the Class VI mirror to heavy goods vehicles for new types of vehicle with effect from 26 January 2006. The directive postponed the fitting of the Class VI mirror for a further year (26 January 2007). In line with common practice, manufacturers applied for a derogation for existing types of new vehicles for a further year to enable them to sell existing stocks of vehicles that had already been manufactured, and up to 4,500 vehicles may have been in this category. | trust this explains why we applied the exemption until 26 January 2008 if a Class VI mirror was not fitted. | would like to assure you that the Department takes the safety of all road users very seriously and my team is active in the area of improving vision for drivers, both direct and indirect. Last year we carried out preliminary work on retrofitting a Class VI mirror to currently exempt vehicles from January 2000 onwards. Although there are a number of collisions involving vulnerable road users and goods vehicles each year, the benefit of a Class VI mirror is limited to circumstances where the vehicle is stationary and about to move off. This is reflected in casualty statistics which show little difference for such collisions involving pre and post 2007 vehicles. Consideration has been given to developing other solutions to provide protection for a wide range of vulnerable road users, and efforts have focussed on ways of providing enhanced vision for drivers. Agreement has recently been reached at international level to permit the replacement of all mirrors by camera systems. These will in future be available on an optional basis so that operators can choose a vehicle specification that is most appropriate for the nature of their operation. Cameras can already be fitted in addition to mirrors. Further work is ongoing in the EU to enable heavy goods vehicles to be more aerodynamic and provide improved safety for vulnerable road users. Engineers from my team are fully engaged in this work which will lead to the development of enhanced type approval standards for new vehicles, allowing operators to have safer vehicles without the need to compromise on load carrying capacity. The Department is also working with the Society of Motor Manufacturers and Traders (SMMT), Transport for London (TfL) and other stakeholders on HGV safety. This activity includes the development and promotion of safer lorry designs. The work is informed by research which has been carried out for DfT and TfL. Manufacturers are being encouraged to develop new vehicle designs that offer better direct vision, and some improved vehicle designs are currently undergoing trials with operators in London. A number of aftermarket devices to detect vulnerable road users have been assessed to develop a method for ranking these devices, and key stakeholders from the operating industry are involved in all of this work. | am grateful to you for raising this incident with me, and wish to assure you that improving direct and indirect vision for drivers is a subject where the Department is taking steps to bring about tangible improvements in safety. lan Yarnold Head; International Vehicle Standards Division
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