Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0237, written 2 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Aug 2022 |
|---|---|
| Reference | 2022-0237 |
| Deceased | Stanley Hardy |
| Coroner | Georgina Nolan |
| Coroner area | Newcastle and North Tyneside |
| Category | Road (Highways Safety) 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.
Newcastle upon Tyne Coroners MISS GEORGINA NOLAN HM ASSISTANT CORONER Civic Centre , Barras Bridge , Newcastle Upon Tyne , NE1 8QH Date: 2 August 2022 Case: 306745 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Grant Shapps, Secretary of State for Transport and Baroness Vere of Norbiton, Parliamentary Under Secretary of State CORONER 1 I am Georgina Nolan, Assistant Coroner for the coroner area of Newcastle and North Tyneside (Lower Ground Floor, Block 1, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QH). 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. 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 1 July 2019 I commenced an investigation into the death of Stanley HARDY aged 83. The investigation concluded at the end of the inquest on 28 July 2022. The conclusion of the inquest was Road Traffic Collision 3 1a Blunt Head Injury 1b 1c II CIRCUMSTANCES OF THE DEATH 4 On 16th June 2019 the deceased (a pedestrian) crossed into the carriageway of Peel Street, Sunderland against a red light. He was hit by a coach turning right into the junction from Toward Street. Although the coach driver saw the pedestrian in the road prior to the collision and applied his brakes, he did not do so forcefully, conscious of the welfare of the passengers travelling in his vehicle. The pedestrian was hit by the coach, thrown to the ground, and suffered serious head injuries from which he died the following day. 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] 5 (1) The coach driver’s evidence was that although he saw the pedestrian in the carriageway he did not forcefully apply his brakes as he had been trained not to do so to protect the welfare of the passengers travelling in his vehicle. (2) Evidence from the Forensic Collision Investigator was that: i. If emergency braking had been applied the coach could have stopped prior to hitting the pedestrian or the collision would have occurred at a significantly reduced speed; and ii. Emergency braking procedures do not form part of the required training for new bus and coach drivers. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have 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 September 2022. I, the coroner, may extend the period. 7 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 I have sent a copy of my report to the Family of the Deceased and Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. 8 9 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. 2 August 2022 for Newcastle upon Tyne Coroners
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 Miss Georgina Nolan HM Assistant Coroner Civic Centre Barras Bridge Newcastle upon Tyne NE18QH Dear Miss Nolan, From the Parliamentary Under Secretary of State Katherine Fletcher MP Great Minster House 33 Horseferry Road London SW1P 4DR. Web site: www.gov.uk/dft 10 October 2022 Thank you. for your report into the circumstances surrounding the tragic death of Stanley Hardy in July 2019. I w9uld like to express my sincerest condolences to Mr Hardy's family and friends. This letter details the Department's response as required by regulation 29 of the Coroners (Investigations) Regulations 2013. The Department has carefully considered the report, and the potential actions that it could undertake to ensure that the tragic circumstances described are not repeated. Safe braking, including in an emergency, is integral to the skills and understanding required of all drivers, not least bus and coach drivers. Your report notes that "emergency braking procedures do not form part of the required training for new bus and coach drivers." I have set out below the· ways in which a bus or coach driver's emergency braking skills are currently assured or promoted. The Category D (bus and coach) driving test includes a requirement for the candidate to ''brake accurately to stop where directed, if need be by performing an emergency stop". In practice, the emergency stop is not conducted as part of the test; this is because technological developments such as brake assist aids will be activated in such situations, and there is therefore little value to testing the skill. This does not mean, however, that the knowledge of how and when to safely perform emergency braking is not promoted, or not taught by reputable trainers. The DVSA has published The National Standard for driving buses and coaches which can be found at: https://assets. publishing. service. gov. uk/governmenUuploads/system/uploads/ attachment data/file/377669/national-standard-for-driving-buses-and coaches. pdf. This is used by individual drivers, learners and trainers and sets out the skills, knowledge and understanding of what is needed to be a safe bus driver. It states (p.16) that a driver must be able to "use the accelerator and brakes correctly to regulate speed and bring the vehicle to a stop safely, taking passengers' comfort and safety into consideration", and also, crucially, to "stop the vehicle safely and under control in an emergency". Advice is also available on the Safe Driving for Life website at: www.safedrivingforlife.info/advice/bus-driving/ In addition, most professional bus drivers are required to hold a Driver Certificate of Professional Competence (CPC) card which is maintained by undertaking 35 hours approved periodic training every 5 years. Drivers have the flexibility to choose the training that is most suitable for their personal development and -the needs of their employer. Questions in the category D theory test and CPC case studies cover the range of emergency braking, normal braking and braking with consideration of passenger safety. The multiple-choice questions in the theory test are based on 3 books: • The Highway Code: www.gov.uk/guidance/the-highway-code • Know your traffic signs: www.gov.uk/government/publications/know-your-traffic-signs • The Official DVSA Guide to Driving Buses and Coaches: www.tsoshop.eo.uk/product/9780115537479/Transport/DriverAnd-V ehicle-Standards-Agency/Bus-Lorry-And-Specialist-VehicleDrivers/ The-Official-DVSA-Guide-to-Driving-Buses-and-CoachesPaperback/ I have attached a copy of the latter guide with this response. These publications help drivers to know and understand how their brakes will perform in an emergency, especially on the benefits of Antilocking Brakes. They al$o provide in'sight into the importance of sound observations and scanning tec;:hniques to help the driver avoid the need to take emergency action. I would also note that the technique required to stop a vehicle in an emergency is no different to what is taught and tested as part of gaining a category B car licence; it is a transferrable skill, and any applicant for a category D licence must already hold a full category B licence. You are correct that there is, in a strict reading of the terms, no "required training" for a bus or coach driver (that is, there is no legally mandated training course). I am however satisfied that there is an appropriate framework in place to promote and support safe braking skills; DVSA's National Standards set out what is expected of bus and coach drivers and the official learning materials support the knowledge and skills that drivers are expected to understand and demonstrate. We therefore do not propose to amend that framework, but given the importance of this matter, the DVSA will ensure that all learning materials where emergency braking skills are covered are reviewed at the next opportunity; and consider whether these sections could benefit from additional or stronger information. It is also relevant to highlight that industry is developing a new professional register for bus and coach instructors. A longstanding register managed by JAUPT (the Joint Approvals Unit for Periodic Training) is to be replaced with a new register developed and operated by the National Register of LGV instructors (NRI). NRI plan to launch the new register later this year, and are talking to employers, training organisations and other stakeholders with the aim of creating a register which has wide support and endorsement across the sector. The work involves activity to define which instructors and assessors will be eligible to join, and develop an NRI examination as a fair and rigorous test of competence to instruct and assess. Yours sincerely, KATHERINE FLETCHER MP MINISTER FOR ROADS ANO REGIONS
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