Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0108, written 7 Apr 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 Apr 2017 |
|---|---|
| Reference | 2017-0108 |
| Deceased | Raymond Berry |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Raymond Dathan Berry
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
• Gareth Llewellyn, Chief Executive, Driver and Vehicle Standards
Agency, The Ellipse, Padley Road, Swansea SA1 8AN
• The Rt Hon John Hayes, Minister of State for Transport,
Department of Transport, Great Minster House, 33 Horseferry
Road, London SW1P 4DR
•
, Managing Director, Honda UK Manufacturing
Limited, Highworth Road, South Marston, Swindon, Wiltshire
SN3 4TZ
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Raymond Dathan Berry was opened on 6th
January 2016. A Pre-Inquest review took place on 14th October 2016 and
the Inquest was concluded on 3rd April 2017.
I found the medical cause of death to be:
1a. Head and Chest Injuries
I determined that Mr Berry had died from injuries he sustained when the
Honda Jazz car he was a passenger in collided with a tree; that he had not
been wearing his seatbelt at the point of collision and that the
1
Supplementary Restraint System had not met the required parameters to
be activated in the collision, no fault having been found by Honda.
4 CIRCUMSTANCES OF THE DEATH
suffered serious injuries and has no
Raymond Berry was travelling home from visiting relatives shortly
before midnight on Christmas Day 2015 in a Honda Jazz car driven by his
Wife, along the B311 Red Road. The car drove onto the roundabout at the
junction with the A322 Guildford Road and crashed into a tree.
Mr Berry was not wearing a seatbelt at the point of collision and
sustained serious head and chest injuries and died at the scene early on
26th December 2015.
recollection of the event.
Airbags in the vehicle were not deployed. Honda UK examined the
vehicle having been contacted by Police who queried the fact the airbags
had not deployed and gave evidence that parameters had not been met to
activate the Supplementary Restraint System. Sensors at the front of the
car were located either side of the front bumper, below the headlights.
The collision with the tree had occurred at the centre of the front of the
car and Honda gave evidence the crumple zone in this area absorbed
much of the impact meaning the rate of deceleration was not sufficient to
trigger the airbags to deploy. It was not possible to calculate the speed at
which the car had been travelling at the point of impact but the Police
Collision Investigation officer estimated this to be around 30 miles per
hour. No faults were found with the vehicle.
5 CORONER’S CONCERNS
The court heard evidence that the Supplementary Restraint System is
only deployed when certain parameters are met. Honda gave evidence
that the fact the SRS did not deploy was due to the crumple zone at the
front centre of the car, incorporating the car engine, absorbing much of
the impact. However Mr Berry died as a result of this collision and
, who was strapped into the car, sustained serious injuries.
The MATTERS OF CONCERN are:
- The parameters required to activate the Supplementary Restraint
System may require adjusting or amendment to activate airbags in
cases where a collision occurs away from the vicinity of the
sensors, for example to the front centre of the vehicle
2
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3. The Chief Coroner
In addition to this report, I am 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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
Signed:
ANNA LOXTON
DATED this 7th day of April 2017
3
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