Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0206, written 19 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jun 2019 |
|---|---|
| Reference | 2019-0206 |
| Deceased | Sophie Lyons |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Greater Manchester Combined Authority, the
Home Office
CORONER
{ am, Alison Mutch Senior Coroner, for the Coroner Area of South Manchester
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
INVESTIGATION and INQUEST
On 5" June 2018, | commenced an investigation into the death of Sophie Louise
Lyons. The investigation concluded on the 16" May 2019 and the conclusion of
the jury was one of;
Narrative: Sophie died as a result of being struck by a car driven by an
uninsured, unlicensed person, whilst he was performing a dangerous
manoeuvre at an illegal car cruising event on a public highway where a
Public Spaces Protection Order was in place.
The medical cause of death was 1a) Traumatic Brain/Head Injury
CIRCUMSTANCES OF THE DEATH
Sophie died as a result of a traumatic brain injury sustained during a high impact
collision with a car whilst attending a car cruising event on 315 May 2018 at
Europa Circle in Trafford Park. Car cruising events are illegal gatherings of car
enthusiasts where people discuss cars, meet friends and in some cases carry
out dangerous driving manoeuvres including speeding, racing and drifting.
Drifting is inducing a deliberate loss of control.
{t was during one such manoeuvre that Sophie was struck. The driver was
unlicensed and uninsured.
Sophie subsequently died in Salford Royal Hospital on 1° June 2018 as a result
of a catastrophic injury.
The contributing circumstances were that, although individuals representing
Greater Manchester Police and the local authority acted with good intentions to
tackle car cruising, the joint partnership approach did not work.
Even though car cruising had been identified as an issue as early as 2014 in the
area, the measures and plans in place to tackle it were ineffective at the time of
Sophie’s death.
In addition, limited resources, complex logistics, bureaucracy and poor
communication all contributed to an ineffective and slow response to preventing
the circumstances surrounding Sophie’s death.
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. —
The inquest heard that car cruising had been an issue in Trafford Park for a
number of years. The problem (and inherent risk to public safety) was one that
both the Local Authority (Trafford MBC) and GMP were aware of.
Attempts to tackle it had been ineffective. Car cruising involved highly
dangerous manoeuvres being carried out on public roads whilst members of the
public were using the roads in significant numbers. The inquest saw video
footage that showed the events leading up to the death of Sophie. It was clear
that an incident involving disastrous loss of control could have happened at any
time that night whilst car cruising was taking place. In addition, the inquest heard
that whilst on this occasion Sophie was the sole fatality it could easily have been
the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection
Order. This had been a joint initiative but the implementation of enforcement
meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-
agency adequately funded and targeted approach was required. In addition the
inquest heard that in an area such as Greater Manchester with multiple Local
Authorities and dense population, a pan Greater Manchester approach would be
required to prevent not just further incidents in Trafford Park but across Greater
Manchester and nationally. The risk being that looking at the problem of car
cruising in isolation could result in it being moved on rather than being dealt with
effectively.
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 14" August 2019. 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 namely 1) Sophie’s family 2) Greater Manchester Police
3)Trafford Council, who may find it useful or of interest.
lam 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.
Alison Mutch OBE
HM Senior Coroner
19/06/2019
2 responses 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.
GREATER G M C A MANCHESTER COMBINED AUTHORITY Ms Alison Mutch OBE HM Senior Coroner South Manchester Coroner's Office | 1 Mount Tabor Street Stockport SK1 3AG 10 October 2019 Dear Madam Inquest into the Death of Sophie Louise Lyons: Regulation 28 Report to Prevent Future Deaths Response of Greater Manchester Combined Authority Greater Manchester Combined Authority (GMCA) responds to the matters of concern contained within the above report. The Local Democracy Economic Development and Construction Act 2009 provides the Statutory framework for combined authorities. A combined authority for an area is established by way of statutory order under the 2009 Act, the Greater Manchester Combined Authority Order 2011 coming into force on 1 April 2011. Initially the GMCA’s functions were limited to transport, economic development and regeneration in accordance with the original scope of the 2009 Act. The 2009 Act was amended in 2016 to make provision for mayors to be elected in combined authority areas (mayoral combined authority), to enable the secretary of state to confer a greater range of functions on combined authorities and for the secretary of state to provide for functions to be exercisable only by the mayor. Since 2017 additional functions have been conferred on the GMCA by way specific statutory orders. The functions of the GMCA/Mayor of relevance to this Inquest are limited to Mayoral police and crime commissioner functions. The Greater Manchester Combined Authority (Transfer of Police and Crime Commissioner Functions to the Mayor) Order 2017 provides for the Mayor for Greater Manchester to be treated, as a police and crime commissioner for the purposes of all police and crime commissioner enactments. The principal functions of a police and crime commissioner under the terms of the Police Reform and Social Responsibility Act 2011 are to: ¢ secure an efficient and effective police for their area; GMCA, Churchgate House, 56 Oxford Street, Manchester, M1 6EU BOLTON MANCHESTER ROCHDALE STOCKPORT TRAFFORD BURY OLDHAM SALFORD TAMESIDE WIGAN * appoint the Chief Constable, hold them to account for running the force, and if necessary dismiss them; * set the police and crime objectives for their area through a police and crime plan; * set the force budget and determine the precept: * contribute to the national and international policing capabilities set out by the Home Secretary; and ¢ bring together community safety and criminal justice partners, to make sure local priorities are joined up. In respect of PCC functions, the Mayor and the Deputy Mayor for Policing and Crime are held to account by the Greater Manchester Police and Crime Panel which is a join committee of the ten constituent councils in Greater Manchester. The Greater Manchester Police and Crime Panel has agreed to the establishment of the Police and Crime Structure with the following meetings at a Greater Manchester level: e Police and Crime Panel e Police and Crime Steering Group e Police and Crime Leads Group The overall role of Greater Manchester Police and Crime Leads and Steering groups is to oversee, drive improvements, work planning and share good practice at a Greater Manchester level, taking into account good practice from within and outside of Greater Manchester. The breadth of work of the groups reflect that of each districts Community Safety Partnership. | attach a copy of the terms of reference for the Steering Group and Leads Group. The GMCA assists with the administration of the police and crime structure. On 26 June 2019, the Police and Crime Leads Group received a report from Jane Le Fevre, Corporate Director Governance and Community Strategy, Trafford Council on car cruising in Trafford Park and the outcome of the inquest into the death of Sophie Lyons. GM Police and Crime Leads were provided with information on the following: e The background to car cruising in Trafford e The partnership activity in support of Public Spaces Protection Orders since their introduction in February 2017 e The work ongoing work undertaken since the tragic incident on 31 May 2018 ¢ The outcome of the Coronial Proceedings e The implications for GM and potential next steps BOLTON MANCHESTER ROCHDALE STOCKPORT TRAFFORD BURY OLDHAM SALFORD TAMESIDE WIGAN Consideration was given to the use by the district councils of their powers to make and enforce Public Spaces Protection Orders and it was agreed that a coordinated approach across Greater Manchester was necessary. Consideration was also given to the work of GMP and their conclusion that 'the GMP response to car cruising required a force-wide plan. It was reported that despite the trigger plan introduced in 2017, police districts had tended to implement plans in their own areas which at times had simply displaced the issue from one area to another. There was support to develop an overarching GM Enforcement Prevention Intelligence (EPIC) Plan and a GMP tactical lead Inspector had been appointed. A number of strategic meetings had been held at which all GMP districts werd represented and AGMA Civil Contingencies Resilience Unit. Whilst the Mayor's functions include holding the Chief Constable to account, the Chief Constable has operational independence and total discretion on decisions concerning the configuration and organisation of policing resources or whether not, to deploy police officers. The powers in relation to Public Spaces Protection Orders are vested solely in the district councils. In conclusion, whilst the Mayor/GMCA has a limited role, function and sphere of influence in this subject matter, the need for a coordinated approach is recognised across Greater Manchester and developments are in train as described above. | trust that this response addresses the concerns identified and | hope it is of assistance. Yours sincerely a Eamonn Boylan Chief Executive Greater Manchester Combined Authority (GMCA) & Transport for Greater Manchester (TfGM) BOLTON MANCHESTER ROCHDALE STOCKPORT TRAFFORD BURY OLDHAM SALFORD TAMESIDE WIGAN
Kit Malthouse MP Minister of State for Crime, Home Office Policing and the Fire Service 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Alison Mutch OBE | HM Senior Coroner Manchester South | Coroner's Court 1 Mount Tabor Street Stockport SK1 3 AG | Dr hh. fran bob, 170419 Death of Sophie Louise Lyons Thank you for your letter of 19" June to the Home Secretary regarding the death of Sophie Louise Lyons. | am responding as the Minister for Policing. | was sorry to read about the circumstances of Ms Lyon's death. Ensuring that our roads are safe is a key element of policing and any death as a result of the actions of another is all the more tragic. | am sorry for the delay in my response. In your report, you raised concerns that enforcement through the use of Public Space Protection Orders (PSPO) was ineffective in Manchester. PSPOs are intended to deal with a particular problem or nuisance in a specific area that is detrimental to the local community's quality of life, by imposing conditions on the use of that area that apply to everyone. They can prove effective in stopping people committing anti-social behaviour in a public place by applying restrictions to how that public space can be used. PSPOs are one of a range of options and tactics which can be used to tackle car cruising. There are a number of public order and road traffic offences that individuals can be charged with and those driving recklessly or inappropriately can have their vehicles seized. As well as anti-social behaviour legislation, some forces have obtained court injunctions covering whole areas which carry a power of arrest for a breach. Although these injunctions have not stopped illegal activity at car cruising events, they have provided a valuable tool to reduce them with regular enforcement operations taking place using local Neighbourhood Officers, Operational Support Teams and drone support. How and when to use these enforcement options is an operational matter for the police to determine in line with local policing plans. It's worth stressing that these events themselves are not illegal and the majority of those attending are genuine car enthusiasts, law abiding and respectful to the local community. Some forces have had success in policing these events by engaging with the organisers through social media or by distributing leaflets and letters to those in attendance, reminding and educating them of their responsibilities and asking for their support in targeting those intent on engaging in illegal activity. In terms of a national approach, the police have recognised the need to work closer together on car cruising to prevent success in one area simply moving the problem to another. A national practitioners group has therefore been set up, bringing together car cruising leads from across the country to share best practice and discuss methods for tackling illegal activity at these events. The first national forum was hosted by Essex Police last year with Greater Manchester Police hosting a meeting this year. Reflecting the importance of this issue, the National Police Chiefs’ Council have also agreed to discuss car cruising at the next Roads Poliging intelligence Forum in October. This will providd the opportunity to facilitate between working between police forces to tackle car cruising and my officials have agreed to attend. More broadly, the Home Office will continue to work closely with the police to ensure that they have access to necessary support to deal with car cruising so our response to illegal activity at these events improves ae we help to prevent future deaths arising in similar circumstances to Ms Lyons. You also raised a number of local matters of concern in your report which, | understand, will be covered in the Greater Manchester Combined Authority's response. Thank you again for raising these important issues with me. ame KIT MALTHOUSE MP Minister of State for Crime, Policing and the Fire Service
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