Prevention of Future Deaths reports · 2016
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 report | 6 Jun 2016 |
|---|---|
| Reference | 2016-0214 |
| Deceased | Ezharul Islam |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Other 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.
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
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.
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.
See every Prevention of Future Deaths report matching Andrew Walker, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.