Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0300, written 1 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2021 |
|---|---|
| Reference | 2021-0300 |
| Deceased | William Buchanan |
| Coroner | Debbie Rookes |
| Coroner area | Dorset |
| Category | Product 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.
1 September 2021
Our ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Sajid Javid, Secretary of State for Health and
Social Care
1 CORONER
I am Debbie S Rookes Assistant Coroner for Dorset 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 5 August 2020 I commenced an investigation into the death of William Buchanan.
The investigation concluded at the end of the inquest on 1 September 2021.
The conclusion of the inquest was Accident. The medical cause of death was:
1a Pneumonia
1b Left rib fractures
1c
II Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease
4 CIRCUMSTANCES OF THE DEATH
William Buchanan decided to obtain a Leo mobility scooter under the Motability scheme. On 7
July 2020, the store manager of Lifestyle and Mobility undertook a home assessment and
completed the Suitability Questionnaire. In the morning on 20 July 2020, the mobility scooter
was delivered to Mr Buchanan and the store manager completed a one to one handover. Later
that afternoon, Mr Buchanan sustained multiple rib fractures when he had an unwitnessed
incident involving his mobility scooter, the exact circumstances of which remain unknown, at his
home address. He was conveyed to Poole Hospital. Despite treatment, he developed pneumonia
and his condition deteriorated. Mr Buchanan died at Poole Hospital, Longfleet Road, Poole at
19.45 on 27 July 2021.
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) Lifestyle and Mobility completed a home assessment including a suitability questionnaire as
Mr Buchanan was obtaining his scooter through the Motability scheme. If clients purchase a
scooter privately, the company has a detailed questionnaire they complete which has been
designed in conjunction with the British Healthcare Trades Association. However, I was very
concerned to learn that elderly individuals can purchase mobility scooters online or in other
stores without any assessment whatsoever being completed to assess their suitability or
competence to use one. This gives rise to a concern that future deaths could occur if action is
not taken.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you Sajid Javid,
Secretary of State for Health and Social Care, 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 27 October 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
Environmental Health Officer, BCP, and
may find it useful or of interest.
I have also sent it to
, Director of Lifestyle and Mobility, who
,
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
1 September 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 Business, Energy & Industrial Strategy Coroner Support Officer The Coroner's Office for Dorset Bournemouth Town Hall Bournemouth BH2 6DY Dear , Paul Scully MP Parliamentary Under-Secretary of State Department for Business, Energy & Industrial Strategy 1 Victoria Street London SW1H 0ET T E +44 (0) 20 7215 5000 engulries@beis.gov.uk W www.qov.uk 21 March 2022 Thank you for sending me a copy of your Prevention of Future Deaths Report dated 9th Febru ary following the inquest into the tragic death of William Buchanan. Please accept my apolo gies in the delay to my response . I am responding on behalf of the Government, and I would be grateful if you could pass on my condolences to the family of Mr William Buchanan, if you have the opportunity to do so. While it appears there is not a product fault/failure in this circumstance, I have set out below the product safety requirements which are pertinent to the issue you raised. The Government's top priority is to keep people safe, which is why goods sold in the UK must meet some of the strictest safety laws in the world. We have in place a product safety regime that establishes what is expected of manufacturers and retailers in relation to the products they make available on the market. The product safety of mobility scooters falls under the Supply of Machinery (Safety) Regula tions 2008 . The regulations place obligations on manufacturers to satisfy the essential health and safety requirements before products are placed on the market and they must also provide consumers with the necessary information and instructions to operate the product safely. Both local trading standards and the Health and Safety Executive enforce the provisions of the Supply of Machinery (Safety) Regulations 2008 to ensure faulty products are removed from the market. The Consumer Protection from Unfair Trading Regulations 2005 also ensure that any market ing literature that advertises or is supplied with the product should not be misleading. Additional support for those with disabilities and/or the elderly is available through the Depart ment for Transport supported registered charity, Driving Mobility. The charity provides profes sional information and assessment to disabled and elderly people allowing them to gain or re tain their independence. I hope this response reassures you that the product safety regime already provides consumers with an appropriate level of protection against unsafe products and seeks to ensure that consumers have the information they need to operate/use products safely. Due to the provisions already in place and limited evidence we have it would be disproportionate to place an obligation on individuals to undertake an assessment before purchasing specific products. I therefore propose that no further action is taken in response to the issues you raise in your report. Yours sincerely, PAUL SCULLY MP Minister for Small Business, Consumers & Labour Markets Minister for London
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