Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0414, written 9 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Dec 2021 |
|---|---|
| Reference | 2021-0414 |
| Deceased | James McKeough |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Grant Shapps Great Minister House Horseferry Road London SW1 1 CORONER I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 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 11th February 2020 I commenced an investigation into the death of James McKeough. His death occurred following a road traffic collision on 3rd February 2020. . The investigation was concluded with the Inquest being held on 6th December 2021. At the end of the Inquest, I concluded that James McKeough died following a Road Traf f ic collision. At the conclusion of the Inquest, I indicated that I would be making a Regulation 28 report addressing concerns that were raised at the Inquest regarding the current standard of lighting and position of this lighting on Slurrykat and similar tankers. 4 CIRCUMSTANCES OF THE DEATH On Monday 3rd February 2020, James McKeough was riding his motorcycle south on the A29 at Bury Hill, near Arundel. He came up behind a tractor towing a Slurry tanker at the top of the hill, travelling in the same direction. The tractor was indicating to turn right. It appears that Mr McKeough was hidden from the tractor driver's view and it seems that Mr McKeough did not see the tractor lights indicating. As the tractor turned right Mr McKeough collided with the offside of the tractor sustaining fatal injuries. 1 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that f uture 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. The positioning and size of of the rear mounted flashing LED lights on the Slurrykat and other types of similar trailers. 2. The f act that these lights emitted a brighter light than the right or left turn indicator light therefore masking the indicator lights. 3. These rear f lashing lights are the same colour as the indicator lights. 4. The indicator light seems to get lost amongst the other flashing lights or can be misinterpreted as an additional non directional warning lamp. 5. On this particular trailer (SlurryKat) the indicator lights are at the same height as the indicators. It was f ound that this issue may have been a contributing factor in Mr McKeough’s death as it appears he did not see the right indicator flashing. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe 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 2nd March 2022. 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: - Forensic Crash Investigators – Sussex 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 f orm. 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. Date 9th December 2021 9 Penelope Schofield, Senior Coroner 2
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.
Penelope Schofield Senior Coroner County Record Office HM Coroners Office Orchard Street Chichester West Sussex PO19 1DD HEAD OF VEHICLE ENGINEERING INTERNATIONAL VEHICLE STANDARDS DEPARTMENT FOR TRANSPORT 3RD FLOOR – GREAT MINSTER HOUSE 33 HORSEFERRY ROAD Web Site: www.dft.gov.uk 2 March 2022 Dear Ms Schofield, Thank you for your Regulation 28 report dated 9 December, sent to the Secretary of State for Transport following the conclusion of your inquest into the death of James McKeough. I am also grateful for a copy of the full inquest documents provided subsequently. I am replying as Head of Vehicle Engineering in the International Vehicle Standards division of the Department for Transport, which leads on vehicle construction standards. You found that the evidence considered during the inquest revealed five matters of concern relating to the configuration of the amber flashing lamps mounted to the rear of the impacted trailer. Specifically, you concluded that the position, size, colour, and brightness of the lamps may have concealed or overwhelmed the active direction indicator and been a contributing factor in this collision. In Great Britain, vehicle lighting is regulated through the Road Vehicles Lighting Regulations 1989 (as amended) (RVLR). In general, the RVLR require that lamps fitted to vehicles show a steady light - exemptions to this requirement exist for direction indicators and warning beacons. The RVLR requires vehicles having a maximum speed not exceeding 25mph or any trailer drawn by it to be fitted with an amber warning beacon if it is to be driven on an unrestricted dual-carriageway. A warning beacon is defined in regulations as a lamp that is capable of emitting a flashing or rotating beam of light throughout 360° in the horizontal plane. Having considered the inquest documents provided, it appears that the two rear flashing amber lamps fitted to the trailer and implicated by the police in the outcome of this collision do not comply with the definition of a warning beacon as they are unidirectional and not capable of emitting a beam of light throughout 360° in the horizontal plane. Based on the evidence supplied, we consider that had a compliant warning beacon been fitted appropriately to the trailer in compliance with RVLR it may have enabled Mr McKeough to differentiate the warning signal from an active direction indicator. However, the evidence does suggest a lack of understanding of the requirements of the RVLR and I will be writing to the National Police Chiefs’ Council, Driver and Vehicle Standards Agency, Society of Motor Manufacturers and Traders, Agricultural Engineers Association and National Farmers’ Union of England and Wales and the National Farmers Union of Scotland to provide guidance and raise awareness of the specific requirements for amber warning beacons fitted to agricultural vehicles used on the road. I hope you find this information helpful and are assured that the Department is taking appropriate action to respond to your concerns. Yours faithfully, Head of Vehicle Engineering International Vehicle Standards
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