Prevention of Future Deaths reports · 2022

Jennifer Davies

Regulation 28 report to prevent future deaths, reference 2023-0098, written 30 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report30 Aug 2022
Reference2023-0098
DeceasedJennifer Davies
CoronerPenelope Schofield
Coroner areaWest Sussex
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 
NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 
THIS REPORT IS BEING SENT TO:  

The Rt Hon Grant Shapps 
The Secretary of State for Transport 
Great Minister House 
33 Horseferry Road 
London 
SW1P 4DR 
1  CORONER 

I am Penelope Schofield, Acting Senior Coroner, for the coroner area of 
Brighton and Hove.  

2  CORONER’S LEGAL POWERS 

3 

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. 
INVESTIGATION and INQUEST 
On 26th May 2020, the then Senior Coroner Veronica HAMILTON-DEELEY 
commenced an investigation into the death of Jennifer Lilian Davies aged 
sixty-nine. The investigation was concluded by me Penelope SCHOFIELD at 
the end of the Inquest on 21st June 2021. The overall conclusion of the inquest 
was a short form conclusion of ROAD TRAFFIC COLLISION.  

4  CIRCUMSTANCES OF THE DEATH 

On 21st May 2020 Mrs Davies was struck by a parcel delivery service vehicle 
when crossing the road in front of the junction with Dyke Road at the Seven 
Dials Roundabout in Brighton. She was knocked to the ground and sustained a 
serious head injury. She was taken to Hospital but despite treatment she did not 
recover from her injuries, and she sadly died on 23rd May 2020. The driver of 
the vehicle has since admitted to causing her death by driving without due care 
and attention. He received a sentence of 3 years and 6 months imprisonment. 

5  CORONER’S CONCERNS 

During the investigation, my inquiries 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:- 

Delivery van drivers (of vehicles under 3.5 Tonnes) are not subject to the current 
Working Time Regulations. However, as in this case, a driver could be required 
to work up to 11 hours a day. Whilst employers can stipulate that their drivers 
should take a 30-minute break there is no legal requirement upon them to do so. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 With the growth in home parcel delivery this is putting lives at risk. Delivery van 
drivers, by the very nature of the work that they do, are being driven in hugely 
populated areas where pedestrians are particularly at risk. 

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 30th October 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: - 

a)  The family of Jennifer Davies 
b)  DPD Group UK 
c)  Precise Couriers Ltd 
d) 

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 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 by the Chief Coroner. 

9 

 Dated 30th August 2022 

Penelope Schofield 
Acting Senior Coroner, Brighton and Hove 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Department for Transport (PDF)
Department 
for Transport 

Penelope Schofield 
Acting Senior Coroner for 
Brighton and  Hove 
The Coroner's Office 
Lewes Road,  Brighton 
BN2 3QB 

!Ri!E<CIE~V!ED 
...  6MAR  2023 

"'"--------------

From the Secretary of State 
Rt Hon Mark Harper MP 

Great Minster House 
33 Horseferry Road 
London
SW1P 4DR 

3 March 2022 

Dear Penelope, 

Thank you for your letter of 5 September to the previous Secretary of State, 
Grant Shapps,  enclosing a copy of your Regulation 28  report dated 30 August 
2022, following the Inquest into the death of Jennifer Lilian  Davies.  I am 
responding as the new Secretary of State and  apologise for the delay in 
sending you this response and  missing your 56-day deadline. 

Firstly,  I would like to say how sorry I was to hear about the tragic death of 
Mrs Davies and my sincere condolences go out to  her family.  It is a tragedy 
when any person dies on  our roads and despite Great Britain having some of 
the safest roads in the world,  I remain concerned about any deaths on  our 
roads. 

Drivers of commercial goods vehicles weighing 3.5 tonnes or less fall  in-
scope of the GB domestic drivers' hours rules ( contained  in the Transport Act 
1968). According to these domestic rules,  in  any 24-hour period the maximum 
driving time is  10 hours and the maximum duty time is  11  hours.  Duty 
includes all  periods of work and driving but does not include rest or breaks.  If 
someone is self-employed, duty time is only time spent driving the vehicle or 
doing other work related to the vehicle or its load.  There are no specific break 
or rest requirements for goods vehicles under these rules. 

However, four provisions of the Working Time Regulations  1998 (as 
amended) apply to drivers operating under these domestic rules.  These are 
an entitlement to 5.6 weeks'  paid annual leave,  an average weekly working 
limit of 48 hours calculated over a specific reference period of normally 17 
weeks (although  individuals can  'opt out'  of this requirement),  health checks 
for night workers,  and an  entitlement to adequate rest.  Adequate rest is 
defined as being long and continuous enough to ensure that a driver does not 
harm themselves, fellow workers or others and that they do not damage their 
health in the long or short term. 

 
 
 
 The current drivers' hours and working time rules are vital in  ensuring the· 
safety of drivers and  others on the road  and  it is  important that these rules are 
adhered to by delivery companies.  Any perceived breaches of the rules can 
be reported to Driver and Vehicle Standards Agency (DVSA),  who are 
responsible for enforcement, via  DVSA's confidential hotline on 0300 123 
9000 or by email to the DVSA intelligence team at 
intelligenceunit@dvsa.gov.uk.  All  calls/emails will be treated  in  confidence. 

In  addition to the drivers' hours 1andworkingtime rules,  delivery companies, 
as employers,  have legal obligations under Health and Safety at Work 
legislation.  For example,  they ~re required,  so fa~ as is reasonably 
practicable, to ensure the healtt;l .and  safety of their employees while at work 
and others who may be  put at risk by their work activities.  In  addition,  they 
have a legal duty as an  employer to manage risks from  fatigue,  irrespective of 
any individual's willingness to work extra hours.  Therefore,  delivery 
companies should have policies and  practices in  place to  manage the risks of 
fatigue to ensure their employees do not drive whilst tired,  putting themselves 
and other road  users at risk.  Any issues can  be reported to the Health and 
Safety Executive on  0300 003  1647 or on-line at: 
www.hse.gov. uk/contact/tell-us-about-a-health-and-safety-issue. htm. 

From the information in  Regulation 28  report,  it states that the driver had 
admitted to causing death by driving without due care and attention,  it does 
not make it clear if a contributing factor was the driver being tired or having 
inadequate rest. 

As I hope you will appreciate,  I must point out that the Department is  unable 
to give a definitive interpretation of the meaning and scope of any legislation 
as this is  ultimately a matter for the courts to determine. We can,  however, 
provide the Department's view. 

If the driver of the vehicle did  not receive the required  adequate rest,  then it is 
the Department's view that the delivery company may not have been 
adhering to the requirements  in  both the working time and  health and safety 
legislation.  If you are able to provide us with the details of his employer, we 
will coordinate with the DVSA and ask them to investigate this case. 

Thank you for the Regulation 28 report.  I hope I have assured you that there. 
are relevant regulations for the driving of light goods vehicles.  I hope you find 
this information helpful and are assured that the Department are taking 
appropriate action to respond to your concerns. 

Yours sincerely, 

Rt Hon  Mark Harper MP 
SECRETARY OF STATE FOR TRANSPORT

Related reports

Other reports by Penelope Schofield

See all →

More reports categorised “Road (Highways Safety) related deaths”

See all →

Track Road (Highways Safety) related deaths

See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.