Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0251, written 20 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2021 |
|---|---|
| Reference | 2021-0251 |
| Deceased | Sarah Lewis |
| Coroner | Debbie Rookes |
| Coroner area | County of Dorset |
| Category | Road (Highways Safety) related deaths · Other 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.
19 July 2021
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Grant Shapps, Secretary of State for Transport
1 CORONER
I am Debbie Rookes, Assistant Coroner for The County of Dorset
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3 INVESTIGATION and INQUEST
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
On 25 November 2020 I commenced an investigation into the death of Sarah Lewis.
The investigation concluded at the end of the inquest on 19 July 2021.
The conclusion of the inquest was Road Traffic Collision.
1a Multiple injuries
1b
1c
II Fluoxetine Toxicity
4 CIRCUMSTANCES OF THE DEATH
On 16 November 2020, Sarah Lewis drove her car to Kennedy's Garage, Lynch Lane, Weymouth,
for an MOT. She was standing on the pavement at the junction of Lynch Lane and McKay Close
waiting for a taxi. A large goods vehicle was being reversed from Lynch Lane into McKay Close
when Ms Lewis started crossing the road behind the lorry. The lorry had its reverse warning
lights on and its reversing alarm was clearly audible over the background noise of the industrial
estate but it is unclear why Ms Lewis did not hear or see these. The lorry driver did not see Ms
Lewis in his mirrors. The lorry struck Ms Lewis at approximately 09.45 on 16 November 2020
causing multiple injuries which were fatal. A post mortem examination revealed a level of
Fluoxetine in excess of the therapeutic range and it is unclear what affect this may have had on
Ms Lewis.
5 CORONER’S CONCERNS
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
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 –
(1) A Large Goods Vehicle was being driven which had reverse warning lights and a reversing
alarm. The driver was assisted by 7 mirrors. A pedestrian was stood on the pavement and she
was not seen by the driver. It is likely that the driver was checking his nearside mirror or the
road around him when the pedestrian stepped out behind the reversing lorry which resulted in a
complete blind spot once she was behind the vehicle.
(2) The evidence I heard is that it is not mandatory for Large Goods Vehicles to be fitted with a
camera at the rear of the vehicle to assist drivers and prevent this blind spot. A lot of drivers
complete journeys alone without a banksman to assist them in safely reversing.
(3) There is no legal requirement for vehicles to have a rear camera and yet this may prevent
future deaths. At the very least it would prevent a large number of accidents.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you Grant Shapps
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 14 September 2021. 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,
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
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
20 July 2021
Signature
Debbie S Rookes
Assistant Coroner for The County of Dorset
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
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.
Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR Web Site: www.gov.uk/dft 13 October 2021 Deborah Rookes Assistant Coroner The Coroner's Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY Dear Mrs Rookes, Thank you for your report dated 19 July 2021 following the conclusion of your inquest into the death of Sarah Kathleen Elaine Lewis, under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The report was received in the Department for Transport (DfT) on 25 August 2021. I am replying on behalf of the DfT as Head of Vehicle Engineering in International Vehicle Standards, which is the lead division on vehicle construction standards. During the inquest you heard evidence that the driver of the Large Goods Vehicle (LGV) had reverse warning lights with a reversing alarm and was assisted by seven mirrors. You also heard that it is not a legal requirement for an LGV to have a rear facing camera, which you believe may be effective in preventing future deaths. All new vehicle types need to be approved prior to their registration and use on UK roads to demonstrate that they comply with a range of technical construction standards. The requirements for indirect vision are set out in the United Nations Economic Commission for Europe (UNECE) Regulation 46 which permits mirrors or camera-monitor systems (CMS) to be fitted to the vehicle to satisfy this requirement. The indirect vision devices fitted to comply with Regulation 46 do not provide a view to the driver directly behind their vehicle. The DfT has been working at international level to develop appropriate requirements to improve vision for drivers around LGVs. This work includes a reversing detection system using cameras, sensors or a combination of these to enable the driver to be aware of an obstacle or person directly behind their vehicle. The technical requirements for the system have been finalised and were formally agreed earlier this year. Following the UK leaving the European Union, a new approval system for vehicles being registered for use in Great Britain is being developed. A call for evidence is planned later this year to gather views on the inclusion of a wide range of technologies that are becoming available, including reversing detection systems. The outcome will inform decisions on future legislation to require these technologies to be fitted to new vehicles. We will hold and record your observations on the use of reversing camera systems within the responses to the call for evidence. I hope you find this information helpful and are reassured that the DfT is engaged in the development of improved vehicle requirements, and that consideration is being given to mandating these to improve protection for vulnerable road users. Head of Vehicle Engineering International Vehicle Standards
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