Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0018, written 8 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jan 2020 |
|---|---|
| Reference | 2020-0018 |
| Deceased | Anthony Carroll |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Emergency services related deaths (2019 onwards) · 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: National Police Chiefs' Council, 1st Floor, 10 Victoria Street, London SW1H 0NN 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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 31/12/2018 I commenced an investigation into the death of Anthony Carroll aged 70. The investigation concluded at the end of the inquest on 08 January 2020. The conclusion of the inquest was: Road Traffic Collision The medical Cause of death was found as: Ia Multiple injuries 4 CIRCUMSTANCES OF THE DEATH – Found by the Jury Anthony Carroll was a local, well-liked Liverpool man. He was on his way home from the Throstles Nest public house at 18:40 on 25/12/2018, having celebrated Christmas Day with his family earlier that day. Anthony headed Northbound on Scotland Road A59, Liverpool. Having not used the pedestrian crossing immediately available outside the Throstles Nest, for reasons unknown, Anthony walked a short distance and crossed the carriageway, on to the central reservation, where he continued to walk along, heading Northbound. A police vehicle Peugeot 308 in the local area, was responding to an emergency call, received at 18:48. Action took by this police officer was to action blue lights, and what he thought was sounding sirens- although sirens were not actually activated along with deploying blue lights-as well as increasing speed from 30 mph up to 63 mph to arrive at place of emergency as soon as possible, heading North up Scotland Road A59. At that time Anthony had arrived on foot approximately 10 metres away from the second pedestrian crossing on Scotland Road, near Hopwood Street, in the central reservation. The police vehicle at this time was in lane 3, 190 metres away. Although the area was well lit here, Anthony was wearing dark clothing, carrying a red bag with him. Anthony stopped and looked left, to check for oncoming traffic for 3 seconds, while standing on the central reservation, at which point the police vehicle was 190 metres away from him. Anthony then steps on to the carriageway, still looking to his left, southbound, towards oncoming traffic. After being in the carriageway 1.3 seconds, Anthony was struck by the police vehicle, at 47 mph. The police officer driving the vehicle carried out an emergency stop in a split second, slightly swerving to his left in doing so, but unfortunately had already collided with Anthony. Both police officers immediately got out of the vehicle to attend to Anthony, after radioing for paramedics. One officer attempted to resuscitate Anthony, and was assisted by an off-duty Emergency Medical Technician (EMT) who was on his way home from work. The EMT found Anthony to be unresponsive at this time. A senior paramedic arrived on scene in 6-7 minutes, who performed CPR and advanced medical techniques on Anthony. Anthony was put on a stretcher and taken by ambulance with blue lights on at 19:21, to the trauma centre in University Hospital Aintree, where he was pronounced dead at 19:40. Under these prevailing circumstances, there was no opportunity for the collision to be avoided. During the post mortem toxicology report, Anthony’s blood alcohol level was found to be 308mg per 100ml. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) 1. During the Course of evidence, it was apparent that the public might be under a misapprehension that police emergency vehicles responding to an emergency are limited to 20 mph above the designated speed limit for the Road has there been publicity that vehicles need to respond safely as quickly as possible. If not, is this under consideration? 2. During the Course of evidence, the police driver and the police passenger believed the sirens were activated and sounding. Analysis of the Siemens VDO Incident Data Recorder demonstrated that in the heat of the emergency both were mistaken and the sirens were not activated. Has a warning light in the cab been considered as a visual indicator or the lights and siren being activated been considered? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04 March 2020. 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 The family of Mr Carroll Merseyside Police I 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. 9 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 08 January 2020
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.
Andre Rebello Senior Coroner for Liverpool & Wirral Gerard Majella Courthouse Boundary Street LIVERPOOL L5 2QD Date: 3rd March 2020 Your ref 03635-2018 Response to Regulation 28 Notice – Inquest into death of Mr Anthony Carroll Dear Mr Rebello, Please accept this correspondence in response to your Regulation 28 Report to Prevent Future Deaths, dated 8 January 2020, following the Inquest touching the death of Mr Anthony Carroll on 25 December 2018. I write on behalf of the National Police Chiefs Council and in my capacity as the chief officer with responsibility for police driving matters. Within your report you raised two matters of concern. I have repeated those matters for ease and provided a full response to both concerns. During the course of evidence, it was apparent that the public might be under a misapprehension that police emergency vehicles responding to an emergency are limited to 20 mph above the designated speed limit for the road. Has there been publicity that vehicles need to respond safely as quickly as possible? If not, is this under consideration? Emergency services have a speed limit exemption under Section 87, Road Traffic Regulation Act 1984, which states: ‘No statutory provision imposing a speed limit on motor vehicles shall apply to any vehicle on an occasion when it is being used for fire and rescue authority, for ambulance purposes or police purposes, if the observance of that provision would be likely to hinder the use of the vehicle for the purpose for which it is being used on that occasion.’ The appropriateness of exceeding the speed limit under this exemption is determined by the prevailing circumstances, environmental conditions, driver qualification and the vehicle concerned. There will be times that it would be unsafe to travel at or in excess of a speed limit even in an emergency. There will also regularly be circumstances where exceeding the speed limit is both justifiable and acceptable. 1st Floor, 10 Victoria Street, London SW1H 0NN T 020 7084 8950 F 020 7084 8951 Whilst a small number of Police forces do have a policy of observing a 20mph cap on designated speed limits, the majority of forces do not. The 20mph cap is not being considered for adoption as a national policy because adopting a single approach does not adequately reflect the dynamic assessment and considerations a trained police driver would need to apply to each scenario where excess speed under the exemption is justifiable and lawful. As I refer to above, the lawfulness of the exemption is dependent upon the prevailing circumstances as the driver determines them to be at that time. For these reasons, the NPCC therefore has no plans currently to undertake any publicity around the exemption allowing police vehicles to safely exceed the speed limit. During the course of evidence, the police driver and the police passenger believed the sirens were activated and sounding. Analysis of the Siemens VDO Incident Data Recorder demonstrated that in the heat of the emergency both were mistaken and the sirens were not activated. Has a warning light in the cab been considered as a visual indicator or the lights and siren being activated been considered? A picture of the emergency lighting control panel is included in the Collison Investigation report submitted by 3.6). The top of two rows of buttons can be seen in the bottom left hand corner of the photograph where the control panel is built into the dashboard fascia of the Peugeot patrol car. (page 42. Photograph When the buttons are pressed to activate the emergency equipment (lights and sirens), these buttons should illuminate to display the activation of the function. The vehicle horn button built into the steering wheel of most cars is also the standard means of activating and cycling through the siren functions (silent/yelp/wail/two- tone/blast - dependent on model fitted), which requires the driver to select using their thumbs (whilst holding the steering wheel) to activate the modes required during an emergency response drive. Although many police response vehicles are similar throughout the United Kingdom, not all of the emergency equipment or control units are standardised within these vehicles. They all have a control panel or switches to operate the emergency equipment and usually a corresponding light to indicate that the equipment has been activated. This is described as a warning light and serves in addition to the noise and pressure waves of the sirens themselves. The expectation and requirement placed upon the officers, reiterated throughout their training, is that they concentrate on their emergency driving and upon the road and hazards ahead, and the imposition of any additional visual distraction within the cab of the vehicle could be detrimental to that. As such, there is no current national proposal to add further indicators for equipment activation to the national police vehicle specifications. Thank you for raising these issues with us for consideration. Yours sincerely Deputy Chief Constable Lancashire Constabulary NPCC Lead for Police Driving
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