Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0403, written 16 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2022 |
|---|---|
| Reference | 2022-0403 |
| Deceased | Zef Eisenberg |
| Coroner | Jon Heath |
| Coroner area | North Yorkshire and City of York |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: (Regulatory Counsel and Disciplinary Officer, MSUK) 1 CORONER I am Jon HEATH, Senior Coroner for the coroner area of North Yorkshire and York 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 06 October 2020 I commenced an investigation into the death of Zef Max EISENBERG aged 47. The investigation concluded at the end of the inquest on 09 December 2022. The conclusion of the inquest was misadventure. 4 CIRCUMSTANCES OF THE DEATH Zef Max Eisenberg died at 16.33 hours on 1 October 2020 at Elvington Airfield, York. The cause of his death was multiple traumatic injuries he suffered when he lost control of the motor car he was driving at approximately 244mph during a National Speed Record attempt. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed a matter 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 MATTER OF CONCERN is as follows: Evidence was heard that the driver’s safety harness crotch straps became detached from the car due to the impact when the car overturned. The car was fitted with a driver’s safety harness which included two crotch straps fastened at a single point mounted to the floor of the car which in turn was fastened to a reinforcement plate which is fitted underneath the car. The force of the impact as the car overturned was such that the reinforcement plate was pulled through the floor of the car thereby detaching the crotch straps from the car. The reinforcement plate complied with FIA regulations. The detachment of crotch strap harness in this instance cannot be said to have made a significant difference to the manner in which the driver died. My concern relates to the regulation and assessment of the strength of cars at the point the harness and the reinforcement plates are fitted. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Motor Sport UK (MSUK) is the governing body of four plus wheeled motorsport in the UK and is recognised as the national sporting authority by the FIA (world governing body). 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 February 10, 2023. 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 THIS REPORT IS BEING SENT TO: 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 Dated: 16/12/2022 Jon HEATH Senior Coroner for North Yorkshire and York Regulation 28 – After Inquest Document Template Updated 30/07/2021
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