Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0227, written 16 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2018 |
|---|---|
| Reference | 2018-0227 |
| Deceased | Tyrone Evans |
| Coroner | Emma Whitting |
| Coroner area | Coventry |
| Category | Road (Highways Safety) 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: THIS REPORT IS BEING SENT TO: JULIE LENNARD, Chief Executive of Driver & Vehicle Licensing Agency, THE RT HON CHRIS GRAYLING MP, Secretary of State for the Department of Transport CORONER tam Emma Whitting Assistant Coroner for Coventry 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7, http://www. legistation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 23/09/2017 | commenced an investigation into the death of Tyrone Declan EVANS. The investigation concluded at the end of the inquest 5th July 2018. The conclusion of the inquest was Road Traffic Collision. CIRCUMSTANCES OF THE DEATH On 15 September 2017 at about 21.30 hours, the Deceased was driving a quad bike along the A444 in the inside lane towards Coventry city centre. The quad bike subsequently collided with the crash barrier on the near side of the road and then with the offiside of a Vauxhall Astra travelling in the same direction and in the same lane. Minutes prior to the collision, CCTV footage from Cyan Park Industrial Estate showed the Deceased performing a “wheelie” with the quad bike. The Deceased was not wearing a crash helmet but was not required by law to do so. At some point during the collision and most likely when the quad bike hit the crash barrier, the Deceased was thrown from the quad bike onto the carriageway causing him to suffer fatal injuries. 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 itis my statutory duty to report to you. The MATTERS OF CONCERN are as follows. ~ (1) The medical cause of death was 1a Blunt Head Injury and the conclusion of the pathologist included the following: “I note the suggestion that he was not wearing a helmet and in my opinion the head injury pattern would support this. As a pathologist | am not in a postion to provide expert evidence on the issue of whether or not a helmet would have prevented his death but clearly when a death is caused by an isolated head injury, one has to suggest that wearing a helmet may well have altered the injury pattern and potentially severity, at least from basic principles”. (2)_ [was informed at the inquest that the quad bike the deceased was driving was an off-road vehicle that had been adapted to use on the road. Yamaha UK confirmed to police that the vehicle had undertaken an Individual Vehicle Approval test by the Vehicle Operator Services Agency (VOSA) and had been issued with a registration number. (3) | was also informed at the inquest by the Collision Investigator that quad bike riders or passengers in England, Scotland and Wales are not required to wear crash helmets. (4) In light of the pathologist’s comments, | am concerned that the absence of any legal requirement for quad bike drivers to wear crash helmets even where such bikes have been legally adapted for road use presents a continuing and potentially avoidable risk of deaths on our roads. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 10 September 2018 but 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: 1! 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. 16/07/2018 Signature. Vie awh Emma Whitting Assistant Coroner Foventry
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.
Department for Transport Emma Whiting HM Coroner - Coventry Cheylesmore Manor House Manor House Drive Coventry CV1 2ND From the Parliamentary Under Secretary of State Jesse Norman MP Great Minster House 33 Horseferry Road London SW1P4DR 1 A SEP 2018 Thank you for forwarding your 'Regulation 28 Report to Prevent Future Deaths’ following the inquest of Tyrone Declan Evans, who tragically passed away on the 23 September 2017, as a result of fatal injuries sustained when his quad bike collided with the crash barrier on the nearside of the road (on the A444) - and then with the offside of a Vauxhall Astra travelling in the same direction and in the same lane. I am sorry to hear of the tragic death of Tyrone Declan Evan, for which I offer my sincere condolences to his family and friends. You state correctly that there is currently no legal requirement for quad bike riders to wear a safety helmet while riding on a public road. The Motor Cycles (Protective Helmets) Regulations 1988, which require motorcyclists to wear a helmet, do not apply to quad bikes as they fall outside the definition given of a motor bicycle, which is defined as a “two-wheeled motorcycle”. However, the Official Highway Code (rule 83) does include advice that riders and passengers of motor tricycles and quadricycles, also called quad bikes, should wear a protective helmet. There are no immediate plans to make the wearing of helmets compulsory,- such a change would require primary legislation. However, the Department is keeping the position under review. There are a number of factors that will need to be taken into consideration such as; the level of use, the safety of riders in a collision and the availability or otherwise of seat belts. Certain models of motorcycles, motor tricycles and quadricycles are only suitable for off-road use, as they do not meet the legal standards for use on roads. Vehicles that do not meet these standards must not be used on roads, pavements, footpaths or bridleways and to do so would be committing an offence. Section 87 of the Road Traffic Act 1988 provides that it is an offence for a person to drive a vehicle of any class on the road without a driving licence. To drive a quadricycle on public roads, a motorist must hold a Category B licence or a former category B1 licence for motor tricycles or quadricycles that are up to 550kg unladen. The categories of licences are set out in the Motor Vehicles (Driving Licences) Regulations 1999 (SI 199/2864 the "1999 Regulations”). Regulation 5 and Schedule 2, Part 1, sets out the various types of licences. Vehicle licensing and registration is governed by the Vehicle Excise and Registration Act 1994 (VERA) (as amended). The Act requires that every mechanically propelled vehicle used or kept on a public road should be licensed and registered. The Driver and Vehicle Licensing Agency (DVLA) believe that there are a total of 12,715 quads within the UK registered for use on public roads. The figure provided is an estimate as quad bikes are not recorded separately and not all records include sufficient information to accurately determine whether or not the vehicle is a quadricycle. Proposed action Improving casualty data for quad bikes Currently quad bikes are not recorded separately in reported road casualties’ data but within the category "other vehicle”. “Other vehicle” includes, for example, quad bikes, ambulances, fire engines, motor caravans, pedestrian controlled vehicles with a motor, refuse vehicles, road rollers, mobile cranes, army vehicles and street barrows. In 2016, 15 people were killed and 107 seriously injured while using a vehicle in the "other” category. This equates to approximately 0.5 per cent of ail the Killed or Seriously Injured (KSI) casualties in Great Britain during 2016. It is likely, therefore, that the number of quad bike users killed or seriously injured is very low. To gain a better understanding, quad bike casualties on public roads could be recorded separately in the police reported road casualty statistics (commonly called Stats 19). Any changes to the Stats 19 requirements has significant implications for police forces, both in terms of the burden of data collection and in terms of IT systems. For this reason, changes to the requirements are only made as part of the quinquennial reviews. The reviews are run by the Department for Transport through the Standing Committee for Road Accident Statistics (SCRAS). SCRAS is made up of police forces, local authorities, central Government and expert users. Any change is subject to agreement between all parties to ensure that the data collected is fit for purpose, as well as not putting too much burden on police forces. Changes to Stats 19 are not permitted outside of the reviews as the cost to the police forces for retraining officers and staff and altering recording systems would become prohibitive. It is only by making a large number of changes at once that software alterations give good value for money. The next Review will probably be later this year. It will then take a year or so before the changes are made, as police forces will need to make a software change to add new codes / variables from the Review. 810? d3S 9 I a a A i a a a a
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