Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0079, written 25 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Mar 2020 |
|---|---|
| Reference | 2020-0079 |
| Deceased | Dudley Howe |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Driver and Vehicle Standards Agency By email: 1 CORONER | am Jacqueline LAKE, Senior Coroner for the area of Norfolk 2 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. 3 INVESTIGATION and INQUEST On 13/10/2017 | commenced an investigation into the death of Dudley Stanley HOWE aged 82. The investigation concluded at the end of the inquest on 25/03/2020. The medical cause of death was: 1a Traumatic Head and Chest Injuries 1b Road Traffic Collision The conclusion of the inquest was: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On 6 October 2017 Mr Howe crossed Station Road, Attleborough. The railway crossing barriers were lowered and traffic was stationary. Mr Howe walked in front of a DAF lorry and stopped. Traffic started to move forward and the lorry collided with Mr Howe who died as a result of his injuries. 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: | understand there is nothing to mandate that specific subjects are covered during HGV training, such as the use and positioning of Class VI (cyclops) mirror which shows the area immediately in front of the lorry, which would otherwise be outside the lorry driver’s view. Some training is provided in respect of use of such mirrors but there are some Industry bodies and Operators who deliver training who do not require all drivers to undergo a Safe Urban Driving or Vulnerable Road User Awareness Course. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 20 May 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. 8 COPIES and PUBLICATION t have sent a copy of my report to the Chief Coroner and to the following Interested Persons: HEE spouse) Director General - Department of Transport | 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 Dated: 25/03/2020 e) Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN
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.
Berkeley House Croydon Street BRISTOL BS5 0DA T (0117) 954 3211 www.gov.uk/dvsa Jacqueline Lake HM Senior Coroner Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN by email: our ref: 2004/00205 27 April 2020 Dear Ms Lake I am writing following your Regulation 28 Report to Prevent Future Deaths, of 25 March. This follows your narrative verdict of the same date, about the death of Dudley Stanley Howe on 6 October 2017. I have set out below the action we intend to take to address your concerns. We will introduce two questions to the driving theory test for new drivers of large goods vehicles. These will be on the topic of class VI (cyclops) mirrors and will increase awareness of the positioning and use of the class VI mirror. We will add these to the theory test question bank for the next reprint in autumn 2020. Professional lorry drivers must complete 35 hours of periodic training every five years to maintain their driver certificate of professional competence (DCPC). We have worked with Transport for London (TfL) and other industry stakeholders to promote such training (often referred to as safe urban driving or vulnerable road user (VRU) awareness courses. These courses typically highlight the blind spots around a lorry’s cab and advise drivers to be extra vigilant, including how to use the latest mirrors and camera technologies. TfL has delivered its safe urban driving (SUD) course to more than 80,000 professional drivers over the last seven years. Although we cannot mandate which DCPC courses are taken by industry bodies and operators, we can increase our efforts to promote SUD and vulnerable road user awareness courses. We will recommend to industry bodies and operators that all drivers take some SUD/VRU training as part of their driver DCPC periodic training. We will highlight the need for lorry drivers to make sure mirrors are properly adjusted on each journey. We will do this across our social media platforms, including on our Twitter and Facebook accounts. We will also look to issue blog posts to heavy vehicle operators and drivers. We will do this within the next six months when drivers and operators are less focussed on the COVID-19 effort and more receptive to other messages and advice. Helping you stay safe on Britain's roads I am happy for a copy of this response to be sent 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
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