Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0404, written 29 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Nov 2019 |
|---|---|
| Reference | 2019-0404 |
| Deceased | Suzanna Bull |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| 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 THIS REPORT IS BEING SENT TO: . ER Lorry Driver al 2. S &J Transport of Coleshill, Warwickshire — Employer of Lorry Driver 3. Scania — Lorry Manufacturer 4., Road Haulage Association 5. Department of Transport CORONER lam Mrs Louise Hunt HM Senior Coroner for Birmingham and Solihull 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 17/10/2017 | commenced an investigation into the death of Suzanna Jayne Bull. The investigation was adjourned under $11 and Schedule 1 of the Coroners and justice Act 2009 pending the outcome of a criminal trial. CIRCUMSTANCES OF THE DEATH Introduction ; This case surrounded the death of Dr Suzanna Bull, a pedal cyclist, who died as the result of a road traffic collision at around 16:00hrs on Monday 9th October 2017, The inquest was adjourned under S11 and Schedule 1 of the Coroners and Justice Act 2009 and a criminal trial concluded in October 2019 when the driver of the lorry was found.guilty of causing death by careless driving. The employer of the lorry driver pleaded guilty to offences under the health and safety legislation. : Since these proceedings it has been assessed by the Senior Coroner that there is insufficient reason to resume the inquest. However, it has been brought to my attention that there is a serious safety concern regarding the circumstances of the death which needs to be addressed. Factual Circumstances The circumstances of the collision are that Dr Bull was riding her pedal cycle along the Pershore Road in the direction of Birmingham City Centre, she was using the designated bus/cycle lane. Dr Bull was passed by Eno was driving a 32 tonne lorry at a point adjacent to West Midlands Police Training Centre Tally Ho, the lorry then had to slow and stop at the junction with Priory Road for a red traffic light. Dr Bull approached the stationary traffic and proceeded towards the advanced stop line using the dedicated cycle lane, she advanced along the nearside of the lorry. The traffic lights turned to green and traffic started to proceed, Dr Bull was ahead of the lorry by a maximum of three bike lengths before the lorry started to catch her up. The lorry then began a left turn manoeuvre and struck Dr Bull dragging her under the front of his vehicle. Dr Bull died as a result of the offside second steered wheel passing over her prone body and trapping her beneath. Evidence in the criminal proceedings centred on an aftermarket dashboard tray which the lorry driver had placed on his dashboard which he then adorned with personal items including a satellite navigation device, an electric fan, ornaments and toys which then obscured his view to the front and nearside. See photo attached. When this table was fitted it created a huge blind spot and had the tray not been placed on the dashboard, Dr Bull would have been seen for at least 5 seconds. With the tray in place it is probable that she could not be seen by the lorry driver. Evidence was given in the criminal trial by DVSA and Scania Tamworth that the fitting of the aftermarket tray was deemed to be dangerous and with the table fitted the vehicle would undoubtedly have failed the MOT. There are no manufacturer details known about the table fitted to the lorry as it was taken from the storeroom at his employer's location and placed into his own vehicle, he was aware that the previous owner had purchased it from the internet to use ina Scania lorry but had since changed vehicles. The tray/table is not a standard fit item supplied by Scania. ‘The Scania group do sell accessories for the vehicles they sell and some newer vehicles are .now supplied with standard fit tray/tables however these are either hinged to fold away or are completely detachable and are not designed to be used when the vehicle is in motion. Please see the letter from lm: supporting the concerns raised. Following a post mortem the medical cause of death was determined to be: 1a) MULTIPLE INJURIES 1b) ROAD TRAFFIC ACCIDENT CORONER’S CONCERNS During the course of the investigation evidence has been provided to me revealing 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. — 14, The fact that the tray creates a blind spot may not be apparent to users. There is no warning on the tray to say that it can create a blind spot when fixed in place whilst the vehicle is moving. Consideration should be given to placing a clear warning on the tray that it should not be fitted. 2. There is no general warning to lorry manufacturers and haulage firms to advise against the use of such trays in a moving vehicle due to the blind spot it creates. Consideration should be given to sending out a warning to all manufacturers and users to highlight the concern. 3. There is rio warning on the dashboard tray to say that it should only be fitted when the vehicle is parked up and stationary. 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 24 January 2020. |, 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, the family and WMP. 1am 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. : : ‘ 29/11/2019 Signature ie og Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull
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.
Berkeley House Croydon Street BRISTOL BS5 0DA T (0117) 954 3211 www.gov.uk/dvsa Louise Hunt HM Senior Coroner Birmingham & Solihull Areas 50 Newton Street Birmingham B4 6NE our ref: 2002/00102 your ref: 121402 – SUZANNA JAYNE BULL (LH/RP) 13 February 2020 Dear Mrs Hunt I am writing following your Regulation 28 Report to Prevent Future Deaths, of 28 January. Your investigation into the death of Suzanna Jayne Bull on 9 October 2017 was adjourned on 17 October 2017 pending the outcome of a criminal trial. The trial concluded in October 2019. You have assessed there is insufficient reason to resume the inquest but have considered there to be a serious safety concern regarding the circumstances of the death. You consider this should be addressed. I am aware that Baroness Vere of Norbiton, Transport Minister for Roads and Security, wrote to you about this on 24 January 2020. I enclose a copy of that letter for reference. We do not have the authority to require warning messages to be put on aftermarket dashboard trays. We can, however, highlight the matters of concern to large goods vehicle (LGV) drivers. I have set out below the action we have taken or intend to take to address your concerns. On 24 January 2020 we published a Moving On blog on GOV.UK. We sent a link to this blog to our distribution list of 68,000 haulage operators. The blog set out the circumstances of Ms Bull’s death and information about the criminal trial. The article reminded all operators and drivers of the importance of making sure the vehicle’s windscreen is always clear. We published a link to this article on our twitter account, which was read around 7,000 times. We continue to highlight this issue across our social media platforms. On the 6 May 2020 we propose to highlight the areas of concern in your report to attendees at our regular Heavy Vehicle Industry Forum. This is a meeting we host with attendees including industry trade bodies, such as the Society of Motor Manufacturers and Helping you stay safe on Britain's roads Traders, the Road Haulage Association and the Freight Transport Association, along with a cross section of other operators. We will also ask them to pass this information on to their members. We publish information on GOV.UK about keeping commercial vehicles safe to drive. Our Guide to Maintaining Roadworthiness is also published on GOV.UK. The Guide includes information on a driver's daily walkaround checks, including ensuring no objects get in the way of their front view. A short video shows some of the checks a driver should do during their daily check. This includes checking there is a clear view through the windscreen. We will be updating this guidance to warn drivers against putting objects in their lorry, which restrict their view. We always check a lorry’s windscreen is clear of obstruction when carrying out our roadside checks. If we find a lorry where the driver’s view is obscured, we will give the driver a prohibition and penalty. The driver must remove the obstruction before we allow the lorry to move on. Our vehicle standards assessors (VSA) check the view of the road from the driver’s seat when carrying out a lorry’s annual test (MOT). The view must not be obstructed by any changes to the original design. The lorry will fail the MOT if an obstruction is present, which affects materially the driver’s view to the front or the sides through the windscreen. VSAs record these as either minor or major defects depending on where the obstruction is and how it affects the driver’s view. I am happy for you to send a copy of this response to all the interested parties as noted at section 8 of your report. You said you were under a duty to send a copy of our response to the Chief Coroner. I confirm I do not wish to make to you any representations about the release or publication of our response by the Chief Coroner. Yours sincerely Gareth Llewellyn Chief Executive
Department for Transport Mrs Louise Hunt HM Senior Coroner Birmingham & Solihull Areas 50 Newton Street Birmingham B4 6NE [RECEIVED Baroness Vere of Norbiton Transport Minister for Roads and Security Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 E-Mail: Web site: www.gov.uk/dit Our Ref: MC/275291 Your Ref: 121402 - Suzanna Jayne Bull 24% January 2020 Thank you for your letter of 26 November 2019 to the Secretary of State, enclosing Regulation 28: Report to Prevent Future Deaths regarding Suzanna Jayne Bull (deceased). | am replying as the Minister responsible for this issue. Further to the Regulation 28 Report you listed some matters of concerns and your opinion that action should be taken. Several actions are planned, although the Department does not have a locus to require warning messages to be placed on aftermarket dashboard trays to indicate they may block visibility during driving (particularly if substantial objects are put on them). During the next few weeks: e the Driver and Vehicle Standards Agency (DVSA) will circulate an update to its distribution list of haulage operators’ information that will state that aftermarket dashboard trays breach testing rules and should be removed when heavy goods vehicles are being driven: e the DVSA will publish similar information on the gov.uk website; e DVSA compliance officers will be made aware of this specific issue in the context of roadside checks (with instances already being liable to be dealt with); and e the Department for Transport will make umbrella bodies (in addition to the Road Haulage Association to whom you sent your letter) such as the Society of Motor Manufacturers and Trades and the Freight Transport Association aware of the areas of concern in your report and seek they also transmit information to their members. | am grateful for your report and the associated letter from fo | Yows. BARONESS VERE OF NORBITON
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