Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0010, written 7 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2017 |
|---|---|
| Reference | 2017-0010 |
| Deceased | Sheila Bowling |
| Coroner | Christopher Dorries OBE |
| Coroner area | South Yorkshire (West) |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, First Mainline 1 CORONER Professor Christopher Dorries OBE, senior coroner for South Yorkshire (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. (1) Where – (a) A senior coroner has been conducting an investigation under this Part into a person’s death (b) Anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c) In the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner 3 INVESTIGATION and INQUEST In November 2013 I commenced an investigation and subsequently opened an inquest into the death of Mrs Sheila Bowling (aged 74). The investigation concluded without an inquest hearing on the 6th March 2015 when I sent a Certificate to the Registrar of Births and Deaths in view of the Crown Court hearing then concluded. Please see separate letter indicating the reason for the delay in forwarding this Regulation 28 report. 4 CIRCUMSTANCES OF THE DEATH Mrs Bowling was crossing a road in Sheffield City Centre around 5.20pm on Wednesday, 6th November 2013. A public service vehicle on the 52 route. Mrs Bowling had virtually reached the far pavement when she was hit by the vehicle. She subsequently died of her injuries in hospital. was driving a First Mainline 5 CORONER’S CONCERNS The investigation 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 The investigation revealed that the vehicle was fitted with a so-called “Drive Clean System”. It is understood that this measures the smoothness of the driving (thus promoting fuel efficiency) and records any sudden braking or steering movements. The learned judge hearing the criminal case at the Crown Court expressed concern about this and is reported to have said the following; “The system his company employs encourages gradual acceleration and deceleration and resistance as far as possible from turning the steering wheel fiercely. It may have been possible had he used greater steering to avoid the lady who was in the last two metres of crossing the road. There was a clear error of judgement in that respect”. It is understood that whilst the learned judge that the monitoring system may have played in the tragedy he was keen for the coroner to exercise Regulation 28 in terms of a report. gave no opinion on the role Notwithstanding the passage of time since this incident, First Mainline may wish to consider the operation of this monitoring system and/or whether the training thereon is open to any improvement. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th April 2017. I may extend the period upon application. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Sheila Bowling Traffic Commissioners I 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. 9 7th February 2017 Christopher P. Dorries OBE HM Senior Coroner South Yorkshire (West) 2
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.
MBA, FCILT Head of Business Performance First South Yorkshire Ltd Midland Road Rotherham S61 ITF : il Professor C.P Dorries OBE HM Senior Coroner The Medico-Legal Centre Watery Street Sheffield $3 7ET Date 20 April 2017 Dear Sir, Ref: Mrs Sheila Bowling (Deceased) Regulation 28 Response Thank you for your letter dated 7" February 2017. First Bus take safety very seriously with respect to all areas of the business i.e. staff, passengers, pedestrians and other road users. There are a number of systems and training programmes in place to ensure our drivers are safe and also drive responsibly with consideration to the impact they have on the environment. On behalf of First South Yorkshire Ltd, | respond as directed to the following matters of concern contained in the Regulation 28 report which refers to an investigation carried out in November 2013 following a fatal road traffic incident. The safety of our customers, staff and other members of the public is our number one priority and all drivers are made aware of this through regular briefings and training (see below). We strongly refute any suggestion that the Drive Green system, or the way in which drivers are rewarded, would have any adverse impact on safety or the way in which a driver would react to an incident of the nature considered by the November 2013 investigation. In fact, the number of collisions in South Yorkshire has reduced by 23.5% since the introduction of Drive Green in 2010. Drive Clean (Green) System The Regulation 28 report refers to “Drive Clean”. We understand this to mean the “Drive Green” system installed on our vehicles, which is a vehicle telematics system used to assist in improving the comfort and safety of our bus services and to improve fuel efficiency. Driver performance is monitored by a range of measures, including Drive Green. Drive Green provides an objective assessment of driver performance and is intended to improve driving styles, reduce our carbon footprint, and reduce the number and severity of road traffic collisions and personal injuries. It analyses driving behaviour and provides objective in-vehicle feedback to the driver via an LED light display and online assessment, highlighting when a vehicle has carried out an unusually sharp braking or cornering manoeuvre. First South Yorkshire Limited Registered in England number 02332529 Midland Road, Rotherham $61 1TF Along with a variety of other tools, it is integrated within First South Yorkshire’s existing driver training programme to embed the behaviour of forward planning and spatial awareness within drivers’ minds. Training: First Bus, including First South Yorkshire, has ‘dedicated to safety’ as one of its core values. To implement this commitment there are a number of safety systems in place to ensure drivers, passengers and other road users are safe and that our drivers drive responsibly. At the heart of these systems and to support the concept of safe, smooth driving is the Smiths System training programme. The Smiths system is based on 5 keys Key1 Aim high in steering Key2 Get the big picture Key3 Keep your eyes moving Key 4 Leave yourself an out Key5 Make sure they see you Our staff are required to undertake this course and receive periodic training as part of their Driver Certificate of Professional Competence (DCPC) accreditation. It is fully integrated into existing driver training, new employee training and ongoing developmental training. Actions taken/proposed: As one would expect of a responsible operator, First Bus and its operating companies, including First South Yorkshire, continuously monitor safety and operational training, and make regular improvements. As part of this ongoing review cycle, in 2016 First Bus, including First South Yorkshire Limited, implemented a new safety training programme called Be Safe. This replaced the previous programme and underpins the First Bus injury prevention strategy. The aim of Be Safe is for everyone within the business to make safety matter personally to them and to strive for zero harm. Be Safe is about being positive and constructive, focusing on colleagues doing the right thing. This is known as positive reinforcement and uses a behaviour management coaching methodology. Constructive conversations are known as touchpoints and focus on safe behaviours across all areas of the business. This concept is actively encouraged and practised by the Operating Company Senior Leadership Team and Depot Leadership Teams. Since late 2015 First South Yorkshire have also recruited a Driving Standards Manager who works closely with drivers to monitor and improve their driving performance. Low performing drivers are now managed through a Driving Standards Support Plan which, has helped reduce collisions and passenger injuries on a year to date measurement. As part of the First South Yorkshire driver reward and recognition scheme, since 2016 each driver is able to earn a modest £20.00 annual safe driving bonus. This payment is subject to meeting qualifying criteria, which requires the driver to have no blame worthy or ‘at fault’ collisions recorded within a 12-month period. It is not in any way linked to Drive Green, which has no connection to a driver’s compensation or bonus payments in First South Yorkshire. Clearly, therefore, Drive Green would have no effect on the likelihood or impact of an incident of this nature. Moreover, even were Drive Green to be linked to a driver’s compensation, all of our drivers are trained to understand that our number one priority is safety and that safety, including avoidance of a collision with a pedestrian, will always take precedence over the desire to provide a smooth ride to passengers on the bus. We strive to continuously improve our overall performance and will not compromise on safety. We therefore trust that this response provides you with confidence that, while we do not accept that Drive Green played any First South Yorkshire Limited Registered in England number 02332529 Midland Road, Rotherham $61 1TF part.in this incident, we have demonstrated positive actions since the tragic events of November 2013 and that we continue to implement new propositions to demonstrate our dedication to safety. Should you have any further questions, please do not hesitate to get in touch. Yours sincerely Head of Business Performance First South Yorkshire Limited Registered in England number 02332529 Midland Road, Rotherham $61 1TF
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