Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0327, written 3 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Oct 2018 |
|---|---|
| Reference | 2018-0327 |
| Deceased | Charlotte Tripper |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, National Express West Midlands. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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. 3 INVESTIGATION and INQUEST On the 5 February 2018, I commenced an investigation into the death of Mrs Tipper. The investigation concluded at the end of the inquest on 19 September 2018. The conclusion of the inquest was a short form conclusion of: Road Traffic Collision The cause of death was: 1a Multiple Injuries b c CIRCUMSTANCES OF THE DEATH Road Traffic Collision 4 i) At 17:03 hours on Monday 22nd January 2018 a fatal road traffic collision occurred on the A4030 Bearwood Road, Bearwood, Birmingham. ii) The sun had set, light was fading, but it was dry and visibility was good. iii) A West Midlands Travel Volvo double decked bus, registered number BU51 RVM, was being driven in heavy traffic in a southerly direction along Bearwood Road by towards the A456 Hagley Road. iv) The bus stopped near to the junction with Poplar Road, which was ahead and to its relative nearside. v) Mrs Tipper was crossing across the mouth of the junction of Poplar Road in a southerly direction, heading towards the carriageway of Bearwood Road. vi) It appears that Mrs Tipper was most likely in the blind spot of the nearside “A” pillar of the bus, as the traffic and bus have started to move. vii) Evidence suggests that as the bus continued to move forward and is likely to have been partially available to be seen in close relative proximity to the nearside “A” pillar of the bus. viii) The bus driver would only have been able to see her in his peripheral vision as they both moved in a southerly direction, unless he had specifically 1 [IL1: PROTECT] looked in the region of the nearside “A” pillar. ix) Evidence from witnesses suggests that once the bus had begun moving forward, the driver’s focus was directed forwards. x) Mrs Tipper then collides with the bus and the nearside wheels of the bus have travelled over her legs causing severe crush injuries. xi) The bus was travelling at a speed of around 6 mph. xii) The driver has continued along Bearwood Road before coming to a halt at traffic lights with the A456 Hagley Road. Whilst stationary, members of the public have informed him there has been a collision. xiii) Sadly, Mrs Tipper later died in hospital as a result of the injuries she sustained. 5 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. – 1. Evidence emerged during the inquest that the driver either through training or discussion with work colleagues had developed a practice of only focussing directly ahead with minimal eye contact with other drivers when emerging from junctions. It appears this was done to so as not to give any other drivers an indication to pull out in front of his bus. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider whether further training or guidance is needed given the technique deployed by the driver maintaining minimal eye contact. My concern is that this may result in a distraction when observations need to take place when emerging from a busy junction. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by1 December 2018. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. I am also under a duty to send the Chief Coroner a copy of your response. 2 [IL1: PROTECT] 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 3 October 2018 Mr Zafar Siddique Senior Coroner Black Country Area 3 [IL1: PROTECT]
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.
National Express West Midlands 51 Bordesley Green Birmingham B9 4BZ nxbus.co.uk Mr Zafar Siddique Black Country Coroners Court Jack Judge Halesowen Street Oldbury West Midlands B69 2AJ 30th November 2018 Dear Sir Thank you for sharing with us your report following the Inquest in to the death of Mrs Charlotte Tipper, which resulted from the tragic accident with our bus on 22nd January 2018. On behalf of myself and National Express West Midlands, I extend our sincere and continued condolences to Mrs Tipper’s family. I write to advise you of our findings and actions to be taken after review of our driver’s comments in evidence at the Inquest. We understand from your report that stated “He had a practice of only focussing directly ahead with minimal eye contact with other drivers when emerging from junctions.” You commented further that “It appears this was done so as not to give any other drivers an indication to pull out in front of his bus.” Mr Nguyen’s line manager was present at the Inquest. English is not his manager believes that he did not express himself well at the Inquest. He has a good record and has been driving with us since May 2005. first language and I shared your report with Training, and together we have considered the content in the training delivered by NXWM (National Express West Midlands) and the messages we are giving to drivers in relation to making observations. General Manager and also with our UK Head of Operational NXWM have a robust and well established Driver training programme which has at its core 5 principles of Defensive Driving. As a philosophy, Defensive Driving is a form of advanced driving that heightens a drivers abilities to predict potential hazards or accidents. I have included with this reply a copy of the Defensive Driving course objectives and an outline of the training (appendix 1). Of relevance to the issue raised I would like to specifically highlight the following driving principles taught to all of our drivers; • See it all – this principle looks at the driver’s field of vision and the driver is coached on how to widen that field of vision. It covers the frequency of mirror checks and why they are important. • Look all around – this section looks further at the field of visibility including how central vision differs from peripheral vision and the driver is coached on avoiding maintaining focus on one object for longer than 2 seconds. • Be seen, be safe – this section highlights the need to see everyone and everything and for them to see us. This section also makes specific reference to the benefit of making eye contact. I have included in appendix 2 some of the relevant trainer notes for these specific areas and the questions that will be put to the driver to challenge and check their understanding. Our trainers are qualified ROSPA instructors and deliver licence acquisition training which covers the use of vision, observations and mirrors in great detail. Appendix 3 highlights relevant sections within the licence acquisition training, which requires specific sign off before competence can be achieved. Each of our drivers have their own copy of the Guidelines to Professional Driving Standards which is prepared by National Express. I have included a copy with my letter (appendix 4), and would like to emphasise to you the following sections; - Human Factors (page 8) highlights to the driver the effects their vehicle and driving have on other road users. On congested roads, particularly in shopping areas, drivers are told to take extra care and especially when there is a need to drive close to the kerb. In particular we highlight to them the risk presented by a pedestrian stepping from the kerb, the risk of mirrors overhanging the pavement and cyclists moving along the nearside of the vehicle. – Awareness and planning focusses on the uncertainties presented by vulnerable road users, which includes pedestrians. This section highlights the importance of mirrors and taking the time to use them properly. In particular we highlight the importance of the driver using mirrors as a tool to gain information about their surroundings, not just as a procedural step in a manoeuvre. Taken from page 14 in this section, we tell drivers “Professional drivers develop a technique for checking mirrors whilst remaining fully aware of what’s happening ahead. Whatever method you adopt it is vital that you use your mirrors effectively and that you act sensibly on what you see. When you’re on the road, hazards can often occur together, or one immediately after another. One may also happen just when the need to begin a manoeuvre to deal with another occurs. You must ensure that you observe every potential danger and are fully prepared to deal with it, if it occurs. The sequence of checks has to be adapted as situations develop. In reality, it takes only moments to carry out and should become second nature without the need to constantly analyse what you’re doing.” , has unfortunately been absent from work since 16th August 2018 (and Our driver, following the Inquest) as he is recovering from an operation on his shoulder. He is not expected to return to work until early in 2019. When taken; returns to work the following action will be Details of action to be taken to prevent the risk of further accidents / death; 1. We will have a discussion with in relation to his comments at the Inquest and look to gain more insight in to why he has felt the need to carry out this practice. We will remind him of the dangers that this way of driving creates. We will consider whether his response requires any further action in relation to training delivery and will highlight this case to our driver trainers. 2. 3. will undergo an assessment of his driving standards and will be provided feedback to enable him to improve as necessary. will undertake a refresher of our defensive driving training and will be assessed against the principles. As I have outlined, the training we deliver at NXWM is aimed at focussing our drivers on the risks of operating a large vehicle in a dynamic environment, where the need to apply their knowledge and experience in relation to the limitations of their field of vision and mirror checks is crucial. Clearly s comments to you at the Inquest are not in line with the principles that we teach and we will be sure to follow this up immediately on his return to work, and prior to him returning to his driving duties. Should you require any further information please do not hesitate to let me know and I will be happy to assist. Yours sincerely, Tom Stables Managing Director National Express UK and Germany West Midlands Travel Ltd. 51 Bordesley Green, B9 4BZ. Registered in England No 02652253. Part of National Express Group
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