Prevention of Future Deaths reports · 2022

Donald Hooker

Regulation 28 report to prevent future deaths, reference 2022-0409, written 21 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report21 Dec 2022
Reference2022-0409
DeceasedDonald Hooker
CoronerLorraine Harris
Coroner areaEast Riding and Hull
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

The Rt Hon Mark Harper MP 
Secretary of State for Transport 
Great Minster House, 
33 Horseferry Road, 
London. S1P 4DR 

Transport Research Laboratory, 
Crawthorne House,  
Wokingham, Berkshire. 
RG40 3GA. 

and 

1 

CORONER 

Miss Lorraine Harris, Area Coroner, 
East Riding of Yorkshire and City of Kingston Upon Hull. 

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 2nd September 2021 I commenced an investigation into the death of Donald 
Frederick HOOKER, aged 70 years. The investigation concluded at the end of the 
inquest on 20th December 2022. The conclusion of the inquest was Road Traffic 
Incident. 

Box 3 of the record of inquest read: 

On 26th August 2021, Donald Frederick HOOKER aged 70 years, was travelling on 
the Humber Bridge when the drive chain of his motorcycle broke.  He collided 
with a vehicle as he drifted to the left causing him to fall off his motorcycle.  His 
crash helmet came off during the incident and he sustained head injuries. Dr 
Hooker was transported to Hull Royal Infirmary where he died on 28th August 
2021. 

1 

 
 His medical cause of death was recorded as:  
1a 
1b 

Multiple Traumatic Injuries 
Road Traffic Incident 

4 

CIRCUMSTANCES OF THE DEATH 

Dr Hooker was an experienced motorcycle user.  On 26th August 2021 he was 
travelling home from work via the Humber Bridge.  When the road conditions 
permitted Dr Hooker began to accelerate appropriately (he had been travelling 
at approximately 30 mph).  He was in 4th gear.  As he accelerated the drive chain 
on his motorcycle broke, and Dr Hooker appeared to drift into a vehicle 
travelling on his nearside.  The collision cause Dr Hooker to fall from his 
motorcycle but as the incident occurred Dr Hooker’s crash helmet came off. 
He sustained severe head and facial injuries.  He was conveyed to Hull Royal 
Infirmary where he died on 28th August 2021. 
There were issues with the drive chain of the bike that were causative of the 
accident, however I had additional concerns regarding the loss of his motor 
cycle crash helmet. 

5 

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 could 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)  This is the second matter that has been referred to my jurisdiction in 
recent months where a motorcyclist has lost his helmet during a 
collision.  During evidence it was adduced that, although it is not a 
common occurrence, it is certainly not unusual for a motorcyclist’s 
helmet to come off or to rotate during a collision. 

(2)  The Forensic Collision Investigator was unable to explain the reason for 
Dr Hooker’s crash helmet coming off.  The chin strap was in place. 

(3)  The Forensic Collision Investigator indicated that she had been unable to 

find any research or scientific data on why such incidents occur.  

(4)  It was adduced in evidence that a kite safety mark may be checked by an 
instructor during motor cycle courses/tests but there did not appear to 
be a known check for ensuring a person has the correct size motorcycle 
helmet. 

(5)  It was acknowledged that many people may now purchase motorcycle 

helmets over the internet and the sizing and fitting may not be 
appropriate. 

(6)  I am concerned that without knowledge of why such incidents are 

occurring, or appropriate education of the riders, that more deaths may 
occur. 

2 

 
 
 
 
 
 
 
 
 
 
 
 6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe 
your department/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 15th February 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 
• 
•  Transport Safety Commission, 

 (son) as a representative of the family 

C/O PACTS, 
Clutha House, 
10 Storey’s Gate, Westminster 
London. SW1P 3AY 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it.   

I may also send a copy of your response to any other person who I believe may find it 
useful or of interest.  

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. 

9 

[DATE]                                              [SIGNED BY CORONER] 

21st December 2022                                  Lorraine Harris 

3

Responses

3 responses 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.

Response from Forensic Collision Investigator (PDF)
Reg.  28  Report to Prevent Future Death - response from the Transport Research  Laboratory - Donald 

Frederick HOOKER 

Hi  All 

Apologies if the below has already been answered in  my absence.  Please see the below regarding the questions 
asked: 

•  What type  of helmet was involved in the Incident (make and hlodel)? 
• 

rs  there an Indication of how tightly the strap was f.stened? A helmet should feel cohlfortable but flt snugly, 
Aloose-flttfng helmet may come off during an accident, however how, after an acddent1 do you determine 
If It was fitting snugly 
•  How old was the helmot? 
•  Where was  the heltnet purchased? Normally when purchased  lit a reputable dealtr, the seller would 

provide flttlng advice and ensure It fits correctly,  however this does not apply when purchased at other 
establishmellts or via  the h1tert1at, 

•  Chin strap maintenance could be an Issue. Was their avidehce ofwear, had it stretched?  These  issues q,n 
only be determined during a forensic examination. This could mean that more awareness training for the 
attending pollce traffic officers and forensic examiners ts  required. 

•  This  Issue  Is lll<ely to become more widespread with the lntrodw:tlon ofelectrlc bll1es and a-scooters or even 

pedal cycles, 

1-The helmet was an  'Uber' flip front motorcycle helmet with a clear visor. It was  ECE  marked 22.05 and therefore 
meets basic UK standards. 
2 -The helmet was fitted with a D-Ring fastener that appeared to be  in  order and  fastened on  inspection, however, I 
am  unable to comment on  how tightly this was fastened when worn. 
3 -This is  an  enquiry that should be  completed by SCU. 
4 -Again, another SCU  enquiry. 
5 -The chin strap appeared to be in order. To  identify whether the material has stretched or suffered any 
deformation the helmet would  need to be sent to the appropriate third party for testing. 

Hopefully, the  above  is of some form of help. 

Kind  regards, 

Forensic Collision  Investigator 
Regional  Forensic  Collision  Investigation  Unit 
Sheffield Office, 
Yorkshire and The  Humber Scientific Support Services 
Operation Complex, Europa Link, Sheffield S9  1XX 

2
Response from The Department for Transport (PDF)
Department for Transport 
Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

28 February 2023 

Miss Lorraine Harris 
Area Coroner 
East Riding of Yorkshire and City of 
Kingston Upon Hull 
The Guildhall, Alfred Gelder Street  
Kingston Upon Hull  
HU1 2AA 

Dear Miss Harris, 

Regulation 28: Report to Prevent Future Death - Inquest of Donald 
Frederick Hooker - Hull and East Yorkshire 

Thank you for your Regulation 28 report dated 21 December 2022, sent to 
the Secretary of State for Transport following the conclusion of your inquest 
into the death of Donald Frederick Hooker. I am also grateful for the further 
details you provided subsequently. I am replying as Head of Vehicle 
Engineering in the International Vehicle Standards division, which leads for 
the Department for Transport on road vehicle construction and safety 
standards, including motorcycle helmets.  

I understand that Dr Hooker fell from his motorcycle after the drive chain 
failed and he collided with a vehicle travelling in an adjacent lane, sustaining 
fatal head injuries when his helmet became detached. You found that the 
evidence considered during the inquest revealed matters of concern relating 
to helmet detachment, sizing and fitting of helmets, and how this may be 
checked and assessed. 

In Great Britain, motorcycle helmets are regulated through the Motor Cycles 
(Protective Helmets) Regulations 1998 (as amended), which require that a 
helmet is fastened securely to the head using retention systems provided for 
that purpose. The technical requirements for helmets, including retention 
systems, are set out in British Standard BS 6658: 1985 and more recently, 
United Nations Economic Commission for Europe (UNECE) Regulation 22. 
These requirements ensure that helmets are designed to maintain position on 
the head, with as little rotation as possible, and prevent the total opening of 
the retaining system, in the event of a crash. To prevent any possible misuse, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 detailed instructions on the use of the fastening devices are provided by 
helmet manufacturers. It remains the responsibility of the rider to follow the 
manufacturer's instructions to ensure that the chin strap is fastened securely, 
including adjusting and maintaining tension in the strap. 

I note from the evidence provided that the chin strap of Dr Hooker’s helmet 
was seen to be fastened post-collision and that the Forensic Collision 
Investigator provided no explanation as to why it became detached during the 
incident. As noted in your report, it is not a common occurrence for a rider's 
helmet to detach during a collision, but research indicates this to be a 
contributory factor in 10% to 14% of casualties. There does not seem to be 
any conclusive evidence on why this might happen, but it is generally thought 
to be due to a failure of the retention system, neglecting to securely fasten the 
retention systems, as well as poorly fitted or loosely worn helmets.  

It is also important to recognise that helmet materials are subject to normal 
wear and tear and hence to a gradual decay of the inherent mechanical 
characteristics of the material itself. Open-cell foams typically used for 
comfort padding bands within helmets’ inner liners often suffer from 
deterioration or relaxation from aging or use, such that helmet fit may worsen 
with extended use or age. As a consequence, a head/helmet size and shape 
mismatch may create a condition where a helmet with a notionally good static 
fit becomes one with a poor dynamic (impact) fit, leading to increased risk of 
loss. To mitigate this risk, helmet manufacturers advise that riders should be 
looking to replace a helmet that has been subject to regular use after 3 to 5 
years.  

The Department recognises the importance of a good fitting and performing 
helmet and has for many years been providing advice and guidance to 
motorcyclists through its Safety Helmet Assessment and Rating Programme 
(SHARP). Working with the motorcycle helmet supply industry, SHARP has 
established the best practice and produced a guidance that offers advice on 
helmet selection and appropriate fitting. This is available on the SHARP 
website at the following link:  https://sharp.dft.gov.uk/get-the-right-fit/.  

The Driver and Vehicle Standards Agency (DVSA) leads for the Department 
on compulsory basic training (CBT) for motorcyclists. Its syllabus contains 
information on helmet fitting and fastening, and DVSA examiners undertake 
checks to ensure that candidates have securely fastened their helmets before 
any riding takes place. Further advice for motorcyclists is available in the 
Highway Code and in the DVSA publication, Riding the Essential Skills, 
available on GOV.UK. 

The Department is committed to improving safety for all motorcyclists and will 
continue to review the technical standards for new helmets under the UNECE 
to ensure they reflect new and emerging technology and offer increasing 
levels of safety, while at the same time promoting and raising awareness of 

 
 
 
 
 
 the importance of motorcycle helmet fitting and their correct usage through 
the SHARP programme. It is important that a helmet fits well and is 
maintained securely on the head if it is to provide its best protection. 

I hope you find this information helpful and are assured that there are 
measures in place, and future actions, to help mitigate the potential risk of 
such incidents occurring in the future. 

Yours sincerely 

Head of Vehicle Engineering
Response from The Future of Transport (PDF)
Dear 

Thank you for writing to TRL and  enclosing a copy of the  Regulation 28 report by Lorraine Harris, Area  Coroner,  East 
Riding of Yorkshire and City of Kingston  Upon Hull. The  report detailed the investigation into the death of Donald 
Frederick Hooker, which was concluded atthe end of the inquest on 20th  December 2022. 

Please  accept my sincere apologies that we are replying two days after the deadline - I would be most grateful if you 
could acknowledge receipt of this email . 

Regarding the matters of concern,  namely: 

(1)  This is the second matter that has been referred to my jurisdiction in  recent months where a motorcyclist 
has lost his helmet during a collision.  During evidence it was adduced that, although it is  not a common 
occurrence, it is certainly not unusual for a motorcyclist's helmet to come off or to rotate during a collision. 

(2)  The  Forensic Collision Investigator was unable to explain the reason  for Dr Hooker's crash  helmet coming 

off.  The  chin  strap was in place. 

(3)  The  Forensic Collision Investigator indicated that she had  been  unable to find any research or scientific data 

on why such  incidents occur. 

(4)  It was adduced in  evidence that a kite safety mark may be  checked  by an instructor during motor cycle 
courses/tests but there did not appear to be a known check for ensuring a person has the correct size 
motorcycle helmet. 

(5)  It was acknowledged that many people may now purchase motorcycle helmets overthe internet and the 

sizing and  fitting may not be appropriate. 

(6)  I am concerned that without knowledge of why such  incidents are occurring, or appropriate education of 

the riders, that more deaths may occur. 

TRL has been  instrumental in supporting the Department for Transport to establish SHARP 
(https://sharp.dft.gov.uk/l. SHARP  is the UK government's ratings scheme for motorcycle helmets and  provides 
consumers with objective information on their safety performance. 

TRL  has  undertaken research on attitudes and  motivations of motorcyclists towards helmets and  protective 
equipment (https://www.trl.co.uk/publications/ppr442). In  summary, "Passion,  performance, practicality: 
motorcyclists' motivations and attitudes to safety - motorcycle safety research  project", found that based  on self-
reported decisions, with respect to choice of bike, helmet, safety gear and avoiding fatigue, there was a wide variety 
of risk perception. Motorcyclists are not a homogeneous group and different safety interventions are required to 
influence their behaviour. 

In 2018, TRL has conducted our own research  into helmet loss, or more specifically our "Helmet Retention Report" 
(https://www.trl.co.uk/publications/helmet-retention-report). This self-funded study had  two specific aims. The  first 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 was to see whether the existing test requirements in ECE  Reg  22.05 relating to dynamic helmet retention (the roll 
test) are  realistically based  and  how well existing helmet designs comply with these tests when  new and  used. The 
second was to identify the mechanism of helmet loss and to quantify the importance of relevant factors such  as 
inertia effects, head geometry and flesh compliance and  misuse. 

Key extracts from this report are: 

•  Statistical data suggested that helmet loss occurs in about 5% of reported collisions involving injury. 
•  The  current form of statutory roll  off testing involves the helmet being drawn forwards on an  arc that causes 
the helmet chin  bar to hook beneath the user's chin  in a manner that would  not be possible in a collision, 
and  is therefore not representative of real  world collisions. 

•  Equally the tests include the retention straps being tightened below the test headform to a level of tightness 
that a user survey has suggested  is inappropriate to real world conditions. A more representative level of 
tightness allows roll off at lower loads. 

•  Many users are wearing helmets that are  reportedly the wrong size for their heads 
•  The  mechanisms for helmet loss are still not fully understood. The  involvement of the sternum and  rotation 

of the neck are believed to be significant factors, which could  be tested in the future. 

To  my knowledge this is the latest research on the subject. In my opinion more work should now be  done, especially 
as  we see  a changing demographic of motorcycle users, for example with increasing numbers of fast-food  and  other 
delivery rider services,  potentially increasing the likelihood for future incidents involving helmet loss. 

I have spoken with colleagues from the Institute ofTraffic Accident Investigators (ITAi) and colleagues at TRL,  who 
raised the following questions with respect the case: 

•  What type of helmet was  involved in the incident (make and  model)? 
• 

Is  there an  indication of how tightly the strap was fastened? A helmet should feel comfortable but fit snugly. 
A loose-fitting helmet may come off during an  accident, however how, after an accident, do you determine 
if it was fitting snugly 
•  How old was the helmet? 

•  Where was the helmet purchased? Normally when purchased at a reputable dealer, the seller would 

provide fitting advice and  ensure  it fits correctly, however this does not apply when purchased at other 
establishments or via the internet. 

•  Chin strap maintenance could  be  an issue. Was their evidence of wear,  had  it stretched?  These  issues can 
only be determined during a forensic examination. This could  mean that more awareness training for the 
attending police traffic officers and  forensic examiners is  required. 

•  This issue  is  likely to become more widespread with the introduction of electric bikes and e-scooters or even 

pedal cycles. 

If you have further questions, or would  like to arrange a call  to discuss this further, please don't hesitate to contact 
me. 

Kind  regards, 

Director, TRL Academy 

TRL  I Crowthorne House  I Nine Mile Ride  I Wokingham  I Berkshire  I RG40  3GA 
-:Ul"\I  . IHfllJIUllf 
I  ~-- OFTRANSPORT 

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2

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