Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0206, written 2 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2016 |
|---|---|
| Reference | 2016-0206 |
| Deceased | Jonathan Weatherley |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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: Trading Standards CORONER lam Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. INVESTIGATION and INQUEST On 24 August 2015. | commenced an investigation into the death of Jonathan David Weatherley. The investigation concluded at the end of the inquest on 1 June 2016. The conclusion of the inquest was a narrative conclusion ...Jonathan Weatherley probably applied braking through his front brakes for an unknown reason. This caused the bonding between the carbon fibre blades and the aluminium fork crown to fail. The bonding material had not adequately bonded the two components. Jonathan Weatherley died as a result of the injuries he sustained in the incident. 4 | CIRCUMSTANCES OF THE DEATH Please see above 5 | 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 fo you. The MATTERS OF CONCERN are as follows. — (1) There were shortcomings in the Recall Notices which were issued in October 2015 and in March 2016. (2) Allthe known problems with the products should be highlighted in a fresh Recall Notice (3) Allthe possible products affected should be highlighted in a fresh Recall Notice (4) Trading Standards and Upgrade Bikes should work together in order to ensure that as wide as possible an audience should be alerted to the fresh Recall Notice. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. _ Cont. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th July 2016. |, 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 — Family solicitors Upgrade Bikes lam 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. 2 June 2016 Caroline Beasley-Murray Senior Coroner Essex
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