Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0303, written 2 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2020 |
|---|---|
| Reference | 2020-0303 |
| Deceased | Holly Chevassut |
| Coroner | Tom Leeper |
| Coroner area | Coventry and Warwickshire |
| Category | Road (Highways Safety) related deaths · Other 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 HOLLY CHEVASSUT (died 2 November 2018) THIS REPORT IS BEING SENT TO: e General Manager GRS Recovery 3-4 Churchlands Business Park Ufton Fields Harbury Leamington Spa CV33 9GX CORONER lam Assistant Coroner Leeper Assistant Coroner for the Coroner area of Coventry and Warwickshire The Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL 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 08/11/2018 an investigation was commenced into the death of Holly Chevassut. The investigation concluded at the end of the inquest on 02/12/2020. The determination of the inquest as to the medical cause of death was a traumatic spinal cord injury owing to impact with a vehicle, and as to conclusion, Road Traffic Collision. CIRCUMSTANCES OF THE DEATH On 31/10/2018 at approximately 1723 hours, the Deceased was walking along Plough Lane, Harbury when she was hit by apparatus protecting the wing mirror of a passing recovery lorry belonging to GRS Recovery. Plough Lane is a rural unlit lane with no footpath on either side. The incident took place in the hours of darkness. The height of the wing mirrors and the protective metal plates on both the nearside and offside of the recovery truck was under 2ms from the road surface. They projected more than 20cms from the widest part of the vehicle. 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 could 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) GRS continues to operate vehicles with mirrors and guards the height of which are under 2 ms from the road surface and which project more than 20 cms from the widest part of those vehicles. Such a configuration creates a risk of personal injury and death to people overtaken by these vehicles. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27/01/2021. |, 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 repo e Holly’s = | e The Local Safeguaraing Chiidren Boar e The Chief Coroner at the Chief Coroner’s Office. lam also under a duty to send a copy of your response to the Chief Coroner and all | Interested persons who in my opinion should receive it. | may also send a copy of your response to any other person who | believe may find it useful or of interest. 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. DATE: 02/12/2020... Signature dA Al = SIGNED BY ASSISTANT CORONER LEEPER
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.
GRS RECOVERY WARWICKSHIRE LTD UNITS 3 & 4 CHURCHLANDS BUSINESS PARK UFTON ROAD, HARBURY CV33 9GX 1. GRS Recovery Warwickshire Limited (“GRS Recovery”) provides this response in relation to the report received under Regulation 28 following the inquest touching upon the death of Holly Chevassut. 2. GRS Recovery provide recovery services for vehicles that have either broken down or have been involved in road traffic accidents. GRS Recovery also provides services to Police forces recovering vehicles connected to criminal offending. This includes working with Warwickshire Police Force. 3. GRS Recovery is a small family business conducted from its premises at 3-4 Churchlands Business Park, Ufton Road, Harbury, Leamington Spa CV33 9GX. GRS Recovery has operated since 1982. 4. GRS Recovery is a private company limited by shares held by . It is run by their daughter, along with in 2020. Due to this, all decision making at company level is undertaken by . , who is a Director of the company has stepped down from her Directorship with undertaking most of the practical aspects of management. 5. The Court will be familiar with role from his evidence. His role is best defined as overseeing the day-today operations of the company, managing the logistics of its fleet and workforce. This includes overseeing the maintenance of the fleet. has been employed with the company intermittently since 1994 but he has remained in the industry in that time. 6. GRS Recovery currently employs 9 members of staff including 6 drivers. The Company operates 15 recovery vehicles including the two Izuzu vehicles referenced in the Regulation 28 report. Preventative Maintenance Inspections take place every 6-12 weeks. Other than the two Izuzu vehicles, the remaining vehicles wing mirrors are above 2 metres from the road surface. GRS Recovery response to Regulation 28 7. GRS Recovery welcomes the directions made by Mr Leeper, Assistant Coroner, under Regulation 28 Report to prevent future deaths following the Inquest into the tragic death of Holly Chevassut. GRS Recovery is committed to ensuring it is compliant with all rules and regulations effecting safe operation of the business. 8. The inquest provided the opportunity to examine the circumstances that led to the tragic death of Holly Chevassut and for GRS Recovery to assess and review the safety of its vehicles going forward. As a result of this, following the directions of Mr Leeper, GRS have outlined the steps taken to address the concerns raised in the report. GRS have also described its future procedure to ensure GRS Recovery learns lessons from the circumstance that led to the loss of Holly Chevassut and continues to ensure the safety of its vehicles in the future. 1. GRS Continues to operate vehicles with mirrors and guards the height of which is under 2ms from the road surface which project more than 20 cms from the widest part of those vehicle. 9. There were two vehicles this report is subject to and they are as follows: - Vehicle 1 Izuzu- This was the vehicle involved in the incident. The wing-mirror protectors were no longer fitted to vehicle 1 at the time the inquest took place. However, the manufacturer fitted wing mirrors exceeded the width required by law by 3cm. Vehicle 2 Izuzu - The inquest also heard that a second Izuzu of the same model may exceed the width required by law as it had the same manufacturer-fitted wing mirrors along with wing mirror protectors. Methods undertaken to reduce the width of the wing-mirrors. 10. GRS Recovery confirm that the wing mirror protectors to Vehicle 2 have now been removed and are no longer fitted to any vehicle under 2 meters from the road surface. 11. GRS Recovery then considered a method to reduce the width of the manufacturer fitted wing-mirrors of both vehicles 1 and 2. GRS Recovery identified that the wing mirrors do not sit centrally on the tubular metal frame. Photo A below (taken from the expert report) shows a birds-eye view of the mirror housing attached to the frame as fitted by the manufacturer. 12. Due to this position, the majority of the mirror is positioned outwards of the tubular metal frame with the remainder inward between the frame and the door to the vehicle. Photo A 13. Therefore, in order to reduce the width of the wing mirrors GRS Recovery has rotated both offside and near side wing mirrors 180 degrees. This places the longer area which faced outwards from the tubular metal frame inward and vice versa. Consequently, this reduces the width of the wing mirrors. GRS Recovery provides the following examples from the offside and nearside mirrors of Vehicle 2 in Photos B and C. Photo B- Nearside door mirror rotated 180 degrees Photo C- Off side door mirror rotated 180 degrees. 14. Following the modifications, this has reduced the width of both vehicles and measurement between the widest parts of the vehicles and the wing mirror. Vehicle 1’s wing mirrors project 19.25 cm from the widest part of the vehicle on each side. Vehicle 2’s wing mirrors project 17cm from the widest part of the vehicle on each side. 15. Both vehicles’ wing mirrors now project less than the 20cm limit prescribed by the The Road Vehicles (Construction and Use) Regulations 1986. 16. We are grateful with the Coroner for raising this issue and providing GRS Recovery the opportunity to respond. GRS Recovery will ensure that this procedure continues in future when it purchases its vehicles.
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.