Prevention of Future Deaths reports · 2016

Ezharul Islam

Regulation 28 report to prevent future deaths, reference 2016-0214, written 6 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Jun 2016
Reference2016-0214
DeceasedEzharul Islam
CoronerAndrew Walker
Coroner areaLondon (North)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

ug North London C Court,
Her Majesty's Coroner for the 29 Wood Stet

Northern District of Greater London Bamet ENS 4BE

(Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680

Fax 0208 447 7689

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO

Transport For London,
14 Pier Walk,

London,

SE10 OES

CORONER

1am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater
London

INVESTIGATION and INQUEST

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.

On the 7" December 2015 | opened an investigation touching the death of Ezharul
Islam , 73 years old. The inquest concluded on the 24" May 2016 The conclusion of
the inquest was “Narrative”, the medical case of death was 1a Aspiration Pneumonia, 1b
Rehabilitation and treatment following Chronic Subdural Haematoma and in 11 Chronic
Subdural Haematoma

CIRCUMSTANCES OF THE DEATH

On the 23" October 2015 at about 10.44 Ezharul Islam fell and struck his head as
the bus he had just boarded moved forward from the bus stop. Mr Islam was
downstairs on a 191 bus and may have been in the process of sitting down when
the bus moved causing him to fall.

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 there was no system to alert passengers that the 191 bus was about to move. In the
past the signal that a bus was about to move would have been the conductor saying hold
on tight and sounding a bell twice in rapid succession. Consideration should be given to
introducing a system that alerts passengers that the bus they are on is about to move.

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by Monday the i August 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

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;-

Representatives of the family
Representatives of the London General Bus Company

| 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.

6" Jund\ 2016

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 Transport for London (PDF)
Transport for London

Transport for London

Dr Andrew Walker Buses Directorate
Her Majesty’s Coroner, Surface Transport
North London Coroners Court, bet ome

‘alestra, 10% Floor
es Wood Street 197 Blackfriars Road

arnet London SEI 8NJ
EN5 4BE
tfl.gov.uk

1st August 2016
Dear Dr Walker,

We were very sorry to hear of Mr Islam’s fall on one of our buses on 23 October
2015 and his subsequent death and wish to pass our condolences to his family.

We have reviewed your Regulation 28 report dated 6 June 2016 and your
recommendation that we should consider introducing a system that alerts
passengers that the bus they are on is about to move.

We were not present at the inquest and therefore were not able to provide you
with information about the actions we take to ensure the safety of our
passengers generally and specifically when buses move.

Your report refers to the past in which you say that the bus conductor signalled
to customers when the bus was about to move by saying hold on tight and
sounding a bell twice in rapid succession. The traditional role of a bus
conductor was to collect fares, maintain the safety of the open platform and
signal to the driver that it was safe to move away from the stop. .The number of
bus conductors significantly reduced during the 1990’s and early 2000’s as the
use of the traditional routemaster was phased out of service. Bus conductors
did not indicate to customers when the bus was to move and the use of the bell
was to advise the driver that customers wishing to board or alight from the bus
had done so. The bell was not used as a method of warning customers that the
bus would be moving.

at Moy, i
Ys
= £

MAYOR OF LONDON Jax VAT number 756 2769 90

Page 2 of 3

With the dominance of one person operated buses bus drivers have been
trained to look out for customers boarding and alighting the bus, ensuring that
elderly and disabled customer and those who are less able or mobile are
seated safely or have taken hold of a hand hold before moving off. Most of our
buses also have a warning signal when the centre doors are about to close and
a visual display and automated voice system informing customers of the
approaching bus stops along the route. Our drivers are also able to speak
directly to passengers to ensure that they are secure on the bus before they
move should they see anything that concerns them.

Much work has been done over the last few years to ensure that safety for our
customers on buses continues to improve. We have installed a large number of
appropriately positioned and designed hand holds throughout our buses
enabling customers to hold on whilst the bus is moving and departing. We have
ensured that there is appropriately positioned priority seating available
supported with suitable signage for elderly and disabled customers and those
less able to stand or mobile. Also through the engine management system of
our buses, we limit the acceleration of the bus, which means that drivers cannot
move forward quickly, and gives more stability for customers whilst the bus is
transitioning from a stationary position either at a bus stop or in traffic. As
mentioned above, we have an ongoing training programme for our bus drivers
to ensure that before they leave a bus stop or accelerate, elderly and disabled
customers have found seats or hand holds. We are also currently investing in a
2 year programme for all bus drivers to enhance their customer service skills
with particular focus on understanding and empathy for customers’ needs which
includes allowing time for elderly customers to be securely positioned prior to
moving from a stationary position.

TIL is also developing a Bus Safety Standard for London Buses which involves
the consideration of a range of innovative and new technologies to continue to
improve safety on buses. Such technologies could include collision avoidance
systems which utilise sensors to warn bus drivers of potential dangers and
trigger Automatic Emergency Braking systems, and Intelligent Speed
Assistance. Other potential design innovations to be considered include
improving wing mirror design and windscreen glazing to reduce the impact of
any collision. Part of the work of the Bus Safety Standard for London involves
London Bus Services Limited
trading as London Buses
whose registered office is
Windsor House

42-50 Victoria Street
London SW1H OTL

Registered in England and Wales
Company number 3914787

VAT number 756 2770 08

London Bus Services Limited is a
company controlled by a local
Atay, authority within the meaning of
e “fs Part V Local Government and

_ e Housing Act 1989. The controlling
MAYOR OF LONDON ea authority is Transport for London.

05/7,
",
%

Page 3 of 3

considering the nature of accidents and collisions on or involving buses and
identifying measures which can be taken to either avoid such accidents and
collisions or mitigate their impact. TfL recently held a seminar with all the bus
manufacturers who supply London’s buses to ensure that they are also fully
engaged and contribute proactively with the Bus Safety Standard and lead the
trials of both new technology and bus design to identify the most appropriate
solutions. Your recommendations will therefore be considered as part of the

Bus Safety Standard for London to find the most appropriate solution.

We strive to provide an excellent service for our customers and safety is
paramount. We continue to consider and implement ways in which to improve
our customers’ experience of using buses in London, ensuring that they are

safe and comfortable.

Yours sincerely

ED ecto: of Operations

Copy to:

MAYOR OF LONDON

205),
My,

<
aye

London Bus Services Limited
trading as London Buses
whose registered office is
Windsor House

42-50 Victoria Street
London SWIH OTL

Registered in England and Wales
Company number 3914787

VAT number 756 2770 08

London Bus Services Limited is a
company controlled by a local
authority within the meaning of
Part V Local Government and
Housing Act 1989. The controlling
authority is Transport for London.

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