Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0237, written 11 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jul 2023 |
|---|---|
| Reference | 2023-0237 |
| Deceased | Mustafa Nadeem |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Child Death (from 2015) · Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) The Rt Hon Mark Harper MP, Secretary of State for Transport - Department For Transport. (2) (3) CORONER , Mayor of the West Midlands, Chair - West Midlands Combined Authority. , Chief Executive - Collaborative Mobility UK. I am James Bennett, Area Coroner for Birmingham and Solihull. 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. INVESTIGATION and INQUEST On 12 December 2022 I commenced an investigation into the death of MUSTAFA NADEEM. The investigation concluded at the end of the inquest. CIRCUMSTANCES OF THE DEATH On 6/12/22 Mustafa was riding an e-scooter to school on the pavement on the B4128, approaching the traffic island with Belchers Lane, Bordesley Green when at 7:58am he inadvertently collided with a pedestrian and fell into the path of a bus that was travelling at slow speed. He suffered fatal injuries and was confirmed deceased at the scene. The e-scooter was authorised for use in Birmingham as part of a national pilot scheme and users were required to have a valid motor-vehicle driving licence and be aged over 18. The e-scooter being used by Mustafa had been unlocked by a 14-year-old friend via an 'app' on his mobile phone. The medical cause of death was conformed at post-mortem examination: Multiple injuries. The formal conclusion as to the death: Death was a consequence of a road traffic collision. 1 2 3 4 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to concern. The MATTERS OF CONCERN are as follows: Hire e-scooters are only available as part of a national pilot scheme. The scheme is implemented locally. Guidance to the providers of hire e-scooters is currently limited to Department for Transport guidance. There is no regulatory body. Hire e-scooters are legally classed as motor vehicles and require the user to have a driving licence. In this case it was also a licencing condition that users were aged 18+. The deceased was using a hire e-scooter to travel to school despite having no driving licence and being aged 12. The account used to access the hire e-scooter belonged to a friend who had no driving licence, was aged 14, and was regularly using an under 16s bank account to pay for rides. I heard evidence that Department for Transport guidance requires a driving licence, age and identity check when an account is created on a mobile device. However, users can easily transfer the account to another device and no further identity and age check is required. In this case the account was originally created on an adult’s mobile phone, but quickly and easily transferred to a child’s mobile phone and payment switched to an under 16s bank account. Department for Transport guidance did not require the e-scooter provider to undertake any age or identity checks at the point of transfer. I heard evidence that the providers of hire e-scooters have no ability to detect if a child’s bank account is being used to pay for rides. In this case, had the provider been able to detect the use of a child’s bank account it would have alerted them to illegal use on the account and action could have been taken. I heard evidence from the head teacher of the deceased’s school that from the outset of the hire e-scooter pilot scheme pupils riding e-scooters illegally was instantly problematic. Upon it being known the school would seize e-scooters pupils would simply abandon them at the end of the road. Despite education and the facts of this death being known, children from the same school and other schools continued to use hire e-scooters illegally. I heard evidence that education is paramount to safe use of hire e-scooters and this requires a collaborative approach. In my view the use of hire e-scooters is not analogous to the supply of other motor vehicles. During the evidence the point was made that the manufacturers of cars/motorbikes do not undertake any checks once the vehicle is with the customer. This can be contrasted to hire e- scooters being readily available, do not involve any face-to-face contact with a responsible adult at the point of unlocking, and are quickly accessed via mobile phone ‘apps’. Children are likely to have many ‘apps’ on their mobile phones and the legal significance of a motor vehicle ‘app’ is likely to be diluted and/or not appreciated at all. In summary: My principal concern is the evidence demonstrates the ease in which children can (illegally) use hire e-scooters. My specific concerns are the evidence demonstrates current hire e-scooter precautions, and education/information, is not effective in preventing children from (illegally) using hire e-scooters. 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. 1. The pilot scheme is run by the Department for Transport. 2. The pilot scheme is implemented locally. In this case by The West Midlands Combined Authority who have confirmed the pilot scheme is about to re-commence in Birmingham. 3. There is no regulatory body or association of e-scooter providers. However, I heard evidence that hire e-scooter providers liaise with Collaborative Mobility UK who are a national organisation for shared transport and work with national and regional authorities on the use of e-scooters. ACTION SHOULD BE TAKEN 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 5 September 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Mustafa Nadeem’s family. (2) (3) Voi Technology Ltd ( (4) (5) Saltley Academy ( (6) Washwood Heath Academy ( (driver of the bus). Headteacher). Headteacher) , Chief Constable, West Midlands Police. , General Manager for the UK). and to the Local Safeguarding Board as the deceased was under 18 years of age. I am also under a duty to send the Chief Coroner a copy of your response. 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. Signature: 11 July 2023 James Bennett, Area Coroner, Birmingham and Solihull 6 7 8 9
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.
Dear Mr. Bennett, 6th September 2023 Th a n k yo u fo r yo u r Re gu la tio n 28 Re p ort of 11 th Ju ly 2023 to Co Mo UK. Th is a rose from th e tra gic d e a th of Mu sta fa Na d e e m in De ce m b e r 2022. Co lla b o ra tive Mo b ility UK (Co Mo UK) is a ch a rity in En gla n d a s we ll a s Scotla n d a n d Wa le s d e d ica te d to th e socia l, e co n o m ic a n d e n viro n m e n ta l b e n e fits o f sh a re d tra nsp o rt. Ma kin g o p e ra tio n a l ch a n ge s to sh a re d tra n sp o rt sch e m e s su ch a s th e e -sco o te r tria ls is n o t so m e th in g Co Mo UK h a s th e p o we r o r re m it to d o. No twith sta n d in g th a t, p a rt o f o u r wa y of a ch ie vin g th e p u b lic b e n e fits d e scrib e d in ou r m e m o ra n d u m a n d a rticle s o f u n d e rsta n d in g is to co n ve n e sta ke h o ld e rs fro m a cro ss p u b lic, p riva te a n d th ird se ctors. Fo llo win g th e In q u e st a n d yo u r le tte r, we h a ve th e re fo re h e ld sp e cific m e e tin gs with th e o th e r two o rga n isa tio n s wh o re ce ive d le tte rs from yo u , ie Tra n sp ort fo r We st Mid la n d s a s p a rt of th e We st Mid la n d Com b in e d Au th o rity a n d th e De p a rtm e n t fo r Tra n sp o rt a s we ll a s co n ve n in g a m e e tin g o f sh a re d e-sco o te r o p e ra to rs. We we re p le a se d to se e a n d n o te th e ch a n ge s wh ich TfWM a n d th e n e w sch e m e o p e ra to r Be ryl a re p u ttin g in p la ce d e scrib e d in th e Ma yo r o f th e We st Mid la n d s’ re sp on se to yo u . We will b e tra ckin g th e se clo se ly to se e h o w th e y wo rk in p ra ctice a n d wh e th e r th e y offe r le sso n s th a t ca n b e a d o p te d in o th e r sch e m e s. We we re a lso p le a se d to d iscu ss th e issu e s with th e De p a rtm e n t for Tra n sp o rt. All sh a re d e -sco o te r sch e m e o p e ra to rs m e e t o r e xce e d th e De p a rtm e n t’s cu rre n t re q u ire m e n ts. An y sh ift in re q u ire m e n ts or gu id a n ce from th e De p a rtm e n t is som e th in g we wo u ld b e ke e n to p la y a p a rt in . We h a ve p u b licly a n d m u ltip ly ca lle d fo r Go ve rn m e n t to le ga lise e -sco o te rs in th e UK, wh ich wo u ld p ro vid e a m o re lo n g-te rm b a sis on wh ich th e y cou ld b e op e ra te d with in or o u twith sh a re d sch e m e s a n d fo r e xa m p le b e fe a tu re d in th e High wa y Cod e . If we id e n tify a n y p ra ctica b le ste p s wh ich cou ld fu rth e r d e cre a se th e ch a n ce s of a n y fu tu re su ch in cid e n ts th e n we will d o a ll we ca n to su p p o rt th e m . With kin d re ga rd s, Chief Executive, CoMoUK 1
From the Secretary of State Rt. Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft Mr James Bennett Area Coroner for Birmingham and Solihull 50 Newton Street, Birmingham B4 6NE 4 September 2023 Dear Mr Bennett, I was very sorry to hear of Mustafa Nadeem’s tragic death and would like to thank you for your investigation and the issues you have highlighted in your report. I am writing to address the concerns you have raised about children accessing rental e-scooters illegally, which were: the effectiveness of current precautions; age and identity checks; and the use of children’s bank accounts to make payments. I will take each of these in turn. I note your comments about the effectiveness of current precautions in preventing children from (illegally) hiring e-scooters, but it is important to acknowledge the steps that e-scooter rental operators have already taken to discourage under-age riding. These vary across the 23 trial areas and include but are not limited to: in-app safety pop-ups and quizzes to ensure awareness of the rules; in-person safety events and training sessions, some held in partnership with the local police; foot patrols by the operator across the trial area; reviews of the location of parking bays; and advertising the rules beyond the app and website, for example in newspapers, on advertising boards, and through the use of stickers on the e-scooter itself. My officials will encourage all operators to continue these additional measures and good practice being developed to help deter under-age riding. It is also important to acknowledge that anyone trying to access an e-scooter illegally, including without a valid driving licence, is committing an offence. I welcome and strongly encourage enforcement of the rules. My officials have been in contact with the police during trials, and local authorities are speaking to police forces in their areas. I note your concern that the Department’s guidance does not require operators to undertake age or identify checks when an account is transferred to a new device. I have reflected on the current guidance issued to local authorities and trial operators regarding licence checking and verification procedures and concluded the minimum standards required from operators should be strengthened to further discourage illegal use. Anyone with a full or provisional driving licence can use a trial e-scooter. The Department’s current guidance to operators and local authorities makes it a requirement for the licence details of users to be ‘captured by operators’ and asks operators to confirm what information, to identify users, they will provide to the police if requested. This should, as a minimum standard, include the name and driving licence details of the driver. The Department will issue updated guidance as soon as possible, and ask all operators to confirm that they are meeting the new minimum requirements no later than two months following publication. As a minimum standard for licence checking, the updated guidance will require all new users registered after the updated guidance comes into force, and all existing active users, to provide their name and licence number and submit a photograph of the front of the licence. These details will need to be stored by the operator so they can be shared with the police if necessary. Licence checking software, or customer service team checks, will also need to be used to check licence validity. The Department understands that the majority of e-scooter operators use third party software to verify licence details. The Department is not involved in the procurement or management of this software, but whatever system is used must be robust. All operators must also ensure they have in- app messaging that states the rules clearly, including the age limit for the trial, and the rule that the person riding the e-scooter must hold a valid driving licence. In the meantime, officials will write to all local authorities and e-scooter rental operators involved in the trials to notify them of an increase in the minimum standards expected, both for checking and validating licences. In addition to the minimum standards, officials will work with trial operators to gather and disseminate examples of additional measures that could further discourage under-age riding, with the aim of raising standards across the industry. I understand that these measures could include a selfie to confirm identity, additional selfie checks when a user switches an account to a new device and at random times when the account is in use, and liveness checks to ensure the selfie is not a photograph or recording. You also raised a concern that operators have no ability to detect if a child’s bank account is being used to pay for rides. An initial review by officials suggests there are currently no systems that would allow a bank to share, with an operator, details of the type of account used to make a payment. This is not a system in use when purchasing other age restricted products and services, but I agree it could be useful in preventing under-age access to e- scooters and have asked my officials to work with operators to understand if anything more could be done to alert them to attempts by under-age riders to gain access to e-scooters. The trials are designed to assess the safety of e-scooters and their wider impacts, and while they are running, we will keep the guidance under review. The Government continues to consider options for future regulation of e- scooters. Any future regulatory changes require completing an impact assessment, equalities assessment and a public consultation. The latter will provide an opportunity for interested parties to shape the new regime before any regulations are introduced. In the meantime, current regulations for e- scooters still apply, and private e-scooters remain illegal to use on public roads. Yours sincerely, Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT
James Bennett Area Coroner, Birmingham and Solihull Dear Mr Bennett, 18/07/2023 Thank you for your Regulation 28 Report of July 11, and for your hearing of Mustafa’s case. It was a tragic accident, and one we absolutely must learn from to ensure it cannot be repeated. As you have identified in your report, Transport for West Midlands (TfWM, which I ultimately Chair) does not have all the levers at its disposal given the e-scooter pilot scheme is ultimately run by the Department for Transport. And as such my response will focus on what we can control locally as the implementors of the pilot. Unlocking e-scooters and ‘selfies’ Under Voi’s West Midlands e-scooter scheme at the time of the incident, users wishing to access a rental e-scooter in the West Midlands had to register to do so and be 18 or over. Registration required a user to submit their name, contact details and upload a photograph of their driving license (minimum requirement to hold a provisional driving license). Voi also required an individual to upload a ‘selfie’ to verify their identity at registration. They used a third-party license checker to verify the license was valid (against DVLA databases) and used AI technology to ensure the selfie matched the image on the license. A selfie check isn’t currently a mandated Department for Transport requirement for registration, but we are steadfast in our belief that this is a necessary additional feature for our regional scheme which is why we implemented it. As a sign-up process we believed this to be safe, and a robust way to stop under-age riders opening accounts and accessing our e-scooters. It is why we are not dropping our demands for a ‘selfie’ check as part of our pilot, and why our new operator Beryl will be using the same security process for registering an account when their scheme goes live. However, in the tragic case of Mustafa, a valid (18+) account was transferred onto another device operated by a 14-year-old. This would have required the 14-year-old to have access to information from both devices to validate the transfer, completed using a verification code sent via text message. A further ‘selfie’ check would not have been requested at the time of transfer. West Midlands Combined Authority, 16 Summer Lane, Birmingham, B19 3SD Tel: 0345 303 6760 wmca.org.uk Clearly therefore there is a need to strengthen security once an account has been opened and passed the original security checks. That is why TfWM and Beryl will be introducing both randomised and targeted identity checks, meaning ‘selfies’ will be required far more frequently to ensure e-scooters are being accessed by valid account holders only. Specifically, we will be undertaking a ‘selfie’ check every time an account transfer takes place, with random checks taking place on ride starts and app openings. We believe this step, which serves as both an active prevention and as deterrent, represents a robust mitigation against a repeat of the circumstances which led to Mustafa’s death. Parking Under our previous pilot scheme, e-scooters could be parked anywhere outside of Birmingham city centre (provided they abided by certain rules, e.g. not left as an obstruction). However, having learnt the lessons of this scheme, our new pilot will be introducing new parking regulations for e-scooters. Beryl’s parking model will only allow riders to park in marked or racked bays. Anyone parking outside these designated areas will be fined immediately, with repeated incursions facing a service suspension or a ban. Clearly we have the power to determine which areas we mark for parking and where we put our racked bays, meaning we will ensure none of these are in the immediate proximity of schools – further disincentivising and deterring underage use. GPS and education As you might be aware, all of Beryl’s e-scooters will be fitted with accurate GPS technology as part of our new pilot scheme. This means the operator will know where vehicles are at any one time, where they have ridden from, and how they were ridden. This information will allow Beryl, alongside TfWM, to target specific areas and specific riders. For example, if frequent activity was seen around a school during peak times Beryl could deploy staff to the school to monitor activities and intervene if required. Equally, Beryl could use monitored activity through GPS to target outreach and education programmes at certain schools or clubs. We remain extremely keen on better education of e-scooters, which is why Beryl is already discussing how - alongside West Midlands Fire Service and West Midlands Police - education programmes will run with institutions where underage riding has previously been identified. These specific interventions are planned to run alongside Beryl’s existing programme of rider training schools. However, we need the education to work both ways, meaning institutions must notify Beryl if they believe they are having problems with e-scooters and underage riding – as your inquest identified was the case at both Saltley and Washwood Heath West Midlands Combined Authority, 16 Summer Lane, Birmingham, B19 3SD Tel: 0345 303 6760 wmca.org.uk academies. Any reports of this nature can be cross-checked with GPS and acted on, and so Beryl will be able to discuss this reporting with institutions as part of their outreach work. Bank accounts It is known that in this instance the 14-year-old account user, after transferring the account onto his phone, changed the payment method to an under-16 account. It was not possible for Voi to identify this account type owing to restrictions on published account information. TfWM aren’t able to directly change this procedure (which is tied up with national regulations), but as Mayor I am committed to work with the Secretary of State as part of the Department for Transport’s efforts to address this concern. Conclusion I believe our previous e-scooter pilot scheme, operated by Voi, demonstrated how e- scooters play a valuable role in providing a sustainable transport option for hundreds of thousands of citizens across the West Midlands, helping to cut car use, congestion, and carbon emissions. However, ensuring these journeys are taken in the safest and most accessible way remains a key priority both for TfWM and our new operator Beryl. That is why we believe the changes outlined above will significantly enhance the safety and security of e-scooters, and ultimately show how we believe we have used the power at our disposal to take action to prevent future deaths. Naturally, I would be very happy to update you again in three months’ time on how effective the steps outlined in this letter have been in the new scheme. Thank you again for writing to me, and I hope my response addresses the concerns your inquest raised. Yours sincerely, Mayor of the West Midlands West Midlands Combined Authority, 16 Summer Lane, Birmingham, B19 3SD Tel: 0345 303 6760 wmca.org.uk
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