Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0123, written 15 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2023 |
|---|---|
| Reference | 2023-0123 |
| Deceased | Natalie Young |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Department for Transport
Great Minster House
33 Horseferry Road
London
SW1P 4DR
FAO: The Rt Hon Mark Harper MP
1 CORONER
I am Samantha Marsh, Senior Coroner for the coroner area of Somerset
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 the 16th April 2022 the then-Senior Coroner, Mr Tony Williams, commenced
an investigation into the death of Natalie Ann Young, aged 92 ("Natalie").
The investigation concluded at the end of the inquest, heard before me, on the
ath February 2023.
The conclusion of the inquest was Accidental death, including medical cause of
death being
la) Lolwer respiratory tract infection
lb) immobility
le) fall with a humeral fracture
11) Frailty
With a finding in box 3 that:
Natalie Ann Young, aged 92, died at Musgrove Park Hospital on the 13th April
2022 from a lower respiratory tract infection which she was more prone to
develop following a period of immobility after an incident on the 9th March 2022
where she was knocked over by a mobility scooter. She sustained a humeral
fracture during this incident but, on the balance of probabilities, the trauma and
insult was too much for her physiological reserve, despite being an very active
and spritely 92 year old lady.
1
4 CIRCUMSTANCES OF THE DEATH
Natalie was an independent (and somewhat spritely) 92 year old lady who had
full mobility. On the 9th March 2022, Natalie was shopping on her own in a
supermarket and was queued at the tills to pay for her groceries. Whilst she was
waiting to be served, another shopper on a mobility scooter has joined the
queue and was waiting, stationary.
Without warning the mobility scooter accelerated forward, ploughing into Natalie
with some force and knocking her over. The forward propulsion of the mobility
scooter was a conscious act of the driver/rider rather than an unforeseen
mechanical or electrical fault.
On becoming aware of the injury caused to Natalie, the mobility scooter driver
flees the scene and has not been identified or heard from since.
An ambulance was called but declined to attend and so staff from the
supermarket transport Natalie to Musgrove Park Hospital where, on admission,
it is discovered that she has sustained a fractured hummerus. Whilst she was
medically fit for discharge throughout the duration of her stay in hospital, she
required physiotherapy and occupational therapy assessments as part of her
discharge planning. Natalie was ultimately discharged from hospital on the 9th
April 2022 with a package of care in place.
Natalie suffered from immobility as a result of the injury, as well as severe pain.
She was re-admitted back into hospital on the 13th April 2022 when she was
diagnosed with severe sepsis and an acute kidney injury due to a lower
respiratory tract infection which had arisen solely as a consequence of the
injuries she had sustained, and the resultant immobility, following a fall. Natalie
died on the same day.
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. -
During the course of the Inquest the evidence revealed that in relation to
mobility scooters there are:
1. No restrictions on those who are able to operate them; i.e. there are no
requirements on the drivers to have vision to a certain standard; to
evidence cognitive ability and competence to a standard to be able to
understand the controls of the vehicle and how to operate them safely; to
be within the acceptable drink drive limit of 80mg/100ml and/or not under
the influence of any other substance.
2
2. No requirements for legal registration and/or record of ownership of the
mobility scooter.
There are many laws and regulations into the safe ownership and operation of a
car or motorbike ; i.e. there are vision tests, cognitive ability requirements, drink-
drive laws etc, all of which are in place to ensure that the person in charge of a
car or motorcycle is safe and competent and does not place those around
him/her at risk of harm or death because of a falling below the acceptable
standard applicable when in control of a mechanically (or electrically, in the case
of PHEV or hybrid) propelled vehicle.
It was, however, apparent on the evidence at Natalie's Inquest that no similar
laws or protections are in place for those who operate mobility scooters meaning
that someone who is legally prevented from driving due to age, infirmity or other
inability is feely able to own, use and operate a mobility scooter without any
restriction whatsoever. The Inquest heard that the current legislation appears to
distinguish between vehicles based on power and speed. However, as was
evident in Natalie 's case, mobility scooters can reach a fast enough speed to
pose a significant risk to the entire community and population but specifically,
small children , pregnant mothers and the elderly who are all particularly
vulnerable to being impacted at speed by a blunt-force object and dying as a
result of the injuries that they sustain.
I am concerned that the lack of regulation around mobility scooters will continue
to result in further deaths, especially when there continues to be no regulation
around those who are deemed fit to operate and use them.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
your organisation has 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 05th April 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:
(i)
(Natalie's son); and
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.
3
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
15th February 2023
4
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.
From the Secretary of State The Rt. Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft 5 April 2023 Samantha Marsh Senior Coroner Somerset Old Municipal Buildings Corporation Street Taunton, Somerset TA1 4AQ Dear Ms Marsh, Thank you for your letter of 15 February 2023, enclosing your Regulation 28 Report to Prevent Future Deaths, relating to the inquest into the death of Natalie Ann Young, who tragically passed away on the 13 April 2022 from a lower respiratory tract infection which she was more prone to develop following a period of immobility after an incident on the 9 March 2022 where she was knocked over by a mobility scooter. I am sorry to hear of the tragic death of Natalie Ann Young, for which I offer my sincere condolences to her family and friends. The ‘Use of Invalid Carriages on Highways Regulations 1988’ sets out the conditions of use for both mobility scooters and powered wheelchairs dividing them into two main categories. The Class 2 type can travel at 4 mph and is primarily intended for use on the footway or footpath. The Class 3 type can travel on the road at up to 8 mph, but must have the facility, via a limiter, to be driven at no more than 4 mph when used on the footpath. Class 1, Class 2 and Class 3 mobility vehicles are not legally defined as motor vehicles and, therefore, the user is not required to have a driving licence or to take a test and the vehicles themselves are not subject to Vehicle Excise Duty (‘road tax’). The consequence of this is that such a mobility scooter is not subject to the drink and drug drive provisions under the Road Traffic Act. However, if the mobility scooter does not comply with the prescribed requirements or conditions of use in the regulations, then the High Court has found that drivers of them can be subject to the drink drive provisions of the Road Traffic Act. There are other less common kinds of mobility scooter, generally faster, wider, or heavier than Class 3 mobility scooters, which are allowed to be driven on the road but not on the pavements. You must hold a driving licence to use those mobility scooters, and they may be subject to Vehicle Excise Duty and require insurance. Users of these mobility scooters will be subject to certain provisions of the Road Traffic Act that do not apply to users of Class 1, Class 2 or Class 3 mobility scooters, including the offences of dangerous driving, causing death by dangerous driving and driving, or being in charge, when under the influence of drink or drugs. All road users have a responsibility to themselves and others to behave in a safe and appropriate manner and this includes mobility vehicle users who ride on the pavement or in pedestrianised areas. Mobility vehicle users are encouraged to have an assessment with a dealer or supplier before acquiring a vehicle and to take training in their use. The Department has developed a comprehensive guide for users of mobility scooters and powered wheelchairs, including legal requirements, eyesight requirements and relevant Highway Code information. It is available to view at: https://www.gov.uk/mobility-scooters-and-powered-wheelchairs-rules There are specific issues relating to vetting and training. Currently, all British Healthcare Trades Association retailers undertake a pre-assessment process which includes testing the skills of the user to ensure they can drive the mobility scooter safely. However, there is a large market in second-hand mobility scooters where no such evaluation of ability is performed. The same issues apply to training where the difficulty is managing the second-hand market. However, there are many training courses available through individual mobility scooter manufacturers and the Mobility Centres offer far more complex and detailed training and assessments. We encourage all users of mobility scooters to consider training to ensure that they can confidently handle their vehicle in all conditions. Creating a consistent, reliable mobility scooter policy which balances the interests of all road users continues to be a challenge. The Department seeks to improve the safe use of mobility vehicles, while ensuring that they remain accessible for the people who use them and for whom they are a lifeline. Proposed action Letter to retailers from Baroness Vere In February 2020 Baroness Vere wrote to retailers of mobility scooters reminding them to advise their customers of the need to show consideration for other pavement users and to encourage their customers to undertake training in the use of the vehicle they are buying. A copy of that letter is attached. We are also supporting the roll-out of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme. Through our DfT Road Safety Research programme, we have provided funding to Driving Mobility, a registered charity with a network of driving assessment centres covering the whole of GB. The training scheme will help retail and hire business to assess a client’s safe driving ability, along with providing information on best practice and recommendations on how to convey that knowledge to others. Short tests will be included in order to judge competency and provide any extra support where needed. Driving Mobility are currently seeking to launch the scheme this summer. Yours sincerely, The Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT
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