Prevention of Future Deaths reports · 2023

Jessica Baker

Regulation 28 report to prevent future deaths, reference 2023-0369, written 5 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Oct 2023
Reference2023-0369
DeceasedJessica Baker
CoronerAndre Rebello
Coroner areaLiverpool and Wirral
CategoryRoad (Highways Safety) related deaths · Child Death (from 2015)
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 before an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 
Secretary of State for Transport 
The Rt Hon Mark Harper MP 
Secretary of State for Education 
The Rt Hon Gillian Keegan MP 

1  CORONER 

I am Andre REBELLO, Senior Coroner for the coroner area of Liverpool and Wirral 

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 

On 05 October 2023 I commenced an investigation into the death of Jessica Evie BAKER 
aged 15.  The investigation has not yet concluded and the inquest has not been heard. 

4  CIRCUMSTANCES OF THE DEATH 

Jessica was a 15 year old pupil who was a passenger travelling on the school coach from 
her home address in Chester to West Kirby Grammar School when the bus was involved in 
a one vehicle road traffic collision. Jessica and the coach driver died in the incident. There 
were over 50 students on board. 
At approximately 08:03 hours a road traffic collision involving this bus has taken place on 
the northbound carriageway of the M53 motorway between junctions 5 and 4. This is in 
the Eastham area of Wirral, Merseyside. The motorway at this point is a generally straight 
stretch of road with three lanes and a hard shoulder in each direction that is separated by 
a corrugated metal barrier on the central reservation. The collision occurred on the 
northbound carriageway and this is bordered by a sloped embankment to the nearside 
that contains shrubbery, trees and general overgrowth. The coach was travelling in lane 2 
of 3 (the central lane) and passing another vehicle to its nearside. Having completed this 
passing manoeuvre, the coach began to move back into lane 1 of 3 (the left hand lane). 
However, it continued to veer gradually towards the nearside. It has crossed the hard 
shoulder before leaving the carriageway altogether, where it has entered the embankment 
and into the overgrowth. It has continued forwards and up the embankment before 
striking a large tree which has then resulted in the vehicle lurching to its right before 
barrel rolling down the embankment and back onto the carriageway coming to rest 
predominantly in the hard shoulder. 
CCTV from within coach shows that prior to the collision, The driver slumps/falls to his left 

Regulation 28 – Before Inquest 
Document Template Updated 30/07/2020 

 hand side prior to the vehicle leaving the motorway and the collision occurring. During the 
course of the vehicle rolling down the embankment, a passenger on the coach, Jessica 
Evie Baker, was partially ejected from the vehicle and become trapped underneath it. This 
has resulted in catastrophic instantly fatal injuries.  Jessica was pronounced deceased at 
scene by attending paramedics at 09.01. The driver was also pronounced deceased at 
scene at 08:50. 
A Roads Policing investigation is ongoing –  the court has directed evidence to be obtained 
and will review the investigation on 20th  March 2024 

5  CORONER’S CONCERNS 

During the course of 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: 

This was a school commuter coach travelling on a motorway. It was constructed after 2001 
and will have had seat belts fitted. Review of CCTV does not show the seatbelts were being 
used. 

This coach had secondary school children on board. Some of the pupils those below 14 
years of age would be expected to wear seatbelts under driver supervision. 

The driver did not appear to be wearing a seat belt 

A distinction should be drawn between school buses in built-up areas and school commuter 
coaches  travelling a distance using A roads and the motorway network –  with regard to the 
availability and use of seatbelts. 

I take judicial notice that using seat belts can prevent some injury altogether, make 
inevitable injury less serve and reduce the risk of fatal injury. 

1.  What advice does government wither through the Department of Transport, or the 
Department of Education give to schools and colleges when contracting for school 
bus commuter contracts –  about the use of seatbelts? 

2.  What public information campaigns are being run about the additional road safety 

provided by the use of seatbelts? 

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 November 30, 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 

Regulation 28 – Before Inquest 
Document Template Updated 30/07/2020 

 Persons 

I have also sent it to 

1.  Carvers Coaches 
2.  Merseyside Police 
3.  Bereaved families 

who may find it useful or of interest. 

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. 

9  Dated: 05/10/2023 

Andre REBELLO 
Senior Coroner for 
Liverpool and Wirral 

Regulation 28 – Before Inquest 
Document Template Updated 30/07/2020

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 and Department for Education (PDF)
Secretary of State for Education 

The Rt Hon Gillian Keegan MP 

Sanctuary Buildings  
20 Great Smith Street 
Westminster  
London  
SW1P 3BT 

From the Secretary of State for 
Transport 
The Rt Hon Mark Harper MP 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

André Rebello OBE  
Senior Coroner Liverpool and Wirral Area  
Hon Secretary Coroners’ Society of England & Wales  
HM Coroner’s Court  
Gerard Majella Courthouse  
Boundary Street  
Liverpool  
L5 2QD  

Dear Mr Rebello  

15 December 2023  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

This is the Department for Education’s (DfE) and Department for Transport’s (DfT) 
joint response to the Regulation 28 Report to Prevent Future Deaths dated 5 
October 2023 This was issued by you following the tragic death of Jessica Evie 
Baker, in a coach crash on the M53, whilst on her way to school. 

We would like to take this opportunity to express our condolences to the family of 
Jessica Baker and to acknowledge the tragic nature of this incident. We would also 
like to thank you for your report. 

The MATTERS OF CONCERN are as follows: 

We note that children above and below 14 years of age were not wearing their seat 
belts. We know that wearing seat belts can prevent some injury altogether, make 
injuries less severe and reduce the risk of fatal injuries. We are also aware that the 
driver of the coach was not wearing his seat belt. 

You asked the following questions: 

1.  What advice does government, whether through the Department for 

Transport, or the Department of Education give to schools and colleges when 
contracting for school bus commuter contracts – about the use of seat belts?  

2.  What public information campaigns are being run about the additional road 

safety provided by the use of seat belts?  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
   
  
   
 
 
 
 
 
 
 
 This response sets out DfE and DfT’s current position and further steps that will be 
taken to strengthen safety on transport to and from schools.  

Current advice and legislation  

Seat belt wearing requirements 

In general, motor vehicle passengers aged 14 and over, being driven on a road 
commit an offence if they do not wear a seat belt where there is one available. This 
offence applied to the school children aged 14 and older travelling on the bus 
involved in the accident.  

In contrast, as regards younger children, the general rule is that the driver commits 
an offence by driving, on a road, a motor vehicle in which there is a passenger under 
the age of 14 who is not wearing a seat belt, and where a seat belt is available. 
However, there is a notable exception. In the case of large buses1, this rule does not 
apply. Therefore, in this instance, the driver was not legally obliged, under road 
safety legislation, to ensure that the younger children on board were wearing seat 
belts, and the children themselves were not legally required to wear them. 

This lacuna is something that the DfT has considered on several occasions over 
many years and has considered again upon receipt of your report. After careful 
consideration, it maintains the position that imposing a legal obligation on coach 
drivers to ensure that all children aged under 14 wear seat belts would be 
inappropriate. Such a requirement is seen as unfair to drivers, considering the 
potential number of children on a coach, and it could pose a distraction with 
significant road safety implications. As a result, the DfT does not intend to make any 
changes to the current seat belt wearing requirements.  

Requirement on bus operators to notify passengers of seat belt wearing 
requirements 

A bus operator is required to take reasonable steps to notify passengers of the 
requirement to wear a seat belt. This can be done through official announcements, 
audio-visual presentations, or prominently displayed signs at each seat. It is an 
offence to fail to comply with this requirement.  To address this, we have requested 
that the Driver and Vehicle Standards Agency (DVSA) remind operators of their 
obligation through a communication to be sent out by the end of December 2023.  
This will help to ensure that passengers are properly informed about the necessity of 
wearing seat belts. 

DfE Guidance to Schools  

Within education, there are three pieces of potentially relevant statutory and non-
statutory guidance: Home to school travel; Health and Safety: Responsibilities and 
Duties for Schools; and Behaviour in Schools.    

It may help to begin by providing some background information about home to 
school travel. The DfE does not issue any guidance specifically directed at schools 
on the provision of home-to-school travel. This is because local authorities (LAs) are 

1 'A large bus has more than 8 seats in addition to the driver's seat and has a maximum laden weight exceeding 
3.5 tonnes. 

2 

 
 
 
 
 
 
  
 
 legally responsible for arranging travel for eligible children. There is no expectation 
that schools will make home-to-school travel arrangements for their pupils, but we 
know that some choose to do this to support families.  In this case, West Kirby 
Grammar School in conjunction with Calday Grange Grammar School had chosen to 
make such arrangements. 

The DfE provides statutory guidance for LAs to support them in the performance of 
their duty to arrange home-to-school travel for eligible children. (Home-to-school 
travel - GOV.UK (www.gov.uk)). This guidance is specifically directed to LAs, but it is 
stated to be ‘of interest’ to schools, academies, parents and travel operators. It 
advises that local authorities may wish to specify in their contracts with school travel 
providers that they will only accept vehicles fitted with seat belts. It also includes a 
section on behaviour on school travel which advises that local authorities and 
schools should collaborate to promote good behaviour on school transport, and that 
schools' behaviour policies should set out what the school will do in response to poor 
behaviour which occurs off the school premises.  

The DfE separately provides schools with advice about their responsibilities under 
health and safety law, in its non-statutory guidance ‘Health and safety: 
responsibilities and duties for schools’ ). This advice makes clear schools must take 
reasonable steps to ensure staff and pupils are not exposed to risks to their health 
and safety. In doing this they are required to ensure that a risk assessment is 
conducted, and measures put in place to minimise any known risk that may arise in 
the course of the school day; including risks related to school premises, or the 
delivery of its curriculum, whether on or off site’.  

The DfE also provides schools with separate advice to help schools understand their 
obligations when undertaking educational visits and other out of school activities in 
its health and safety on educational visits guidance. However, neither of these 
documents relate to Home to School transport or the wearing of seat belts on buses 
as these are not health and safety issues in strict legal terms. 

DfE’s ‘Behaviour in schools’ guidance is directed at headteachers and school staff 
and covers behaviour outside of school premises. It says ‘schools have the power to 
sanction pupils for misbehaviour outside of the school premises to such an extent as 
is reasonable’ and ‘schools should collaborate with local authorities to promote good 
behaviour on school transport.’ 

Future steps to strengthen transport safety 

The safety of children and young people is of paramount importance to us. We want 
to take the opportunity to learn from this deeply tragic accident and we take your 
concerns very seriously.  

Both Departments agree with the comments made in your report that education is a 
central feature of promoting road safety.  

This is something the DfT takes very seriously and is why DfT runs its THINK! 
campaigns. The THINK! team produces educational materials for schools and 
dedicated advice for drivers and other road users. DfT recognises that the section of 
the THINK! website dealing with road safety laws would benefit from the addition of a 

3 

 
 
   
    
 
 
 
 reference to children aged 14 plus being personally responsible for wearing their 
seat belt. This has now been added and DfT Officials are reviewing further 
opportunities to increase the presence of seat belt wearing advice for passengers 
and drivers. DfT will do this by the end of the year.  

Your covering e-mail cited the famous “Clunk Click” advertisements on television 
which heralded the introduction of mandatory seat belt wearing in the late 1970s and 
early 1980s. Our approach to road safety campaigns has changed and now is 
evidence-based and targeted both in terms of material and media.  

THINK! is the DFT’s long-running and respected road safety campaign. THINK! aims 
to reduce the number of people killed and seriously injured on the roads by changing 
attitudes and behaviours among those at most risk. In 2021 30% of car occupant 
fatalities were not wearing a seat belt compared with 19% in 2013. 17-29 year olds 
are over represented in fatalities: 40% v 30% of all car occupants in 2021. The team 
is currently working on a dedicated campaign to promote seat belt wearing; the first 
national seat belt campaign since 2011. It will be launched in March 2024. This 
campaign will be targeting those most at risk – young men. The campaign will also, 
however, provide an opportunity to raise awareness on a national scale and can 
include wider messages, for example about wearing seat belts on buses and 
coaches, within the stakeholder toolkit and social content. 

DfE will work closely with the THINK campaign team at DfT to ensure education 
materials on seat belt compliance are shared with education settings and are 
embedded. This will include sharing DfT’s updated guidance on seat belt compliance 
and messaging from campaigns on seat belt safety in communications to the sector 
as well as across our own digital channels. This will coincide with the update to DfT’s 
website and campaign launch in March 2024. DfE also proposes to make a small 
amendment to the existing statutory guidance on home-to-school travel to state that 
parts of it, including the sections on promoting good behaviour in transport, will be of 
particular relevance to schools that arrange home-to-school transport for their pupils. 
DfE will aim to do this early in the New Year. 

We would like to take the opportunity to thank the Coroner for bringing this matter to 
our attention and giving us the opportunity to respond.  

Yours sincerely 

Rt Hon Gillian Keegan MP 
SECRETARY OF STATE FOR 
EDUCATION 

Rt Hon Mark Harper MP 
SECRETARY OF STATE FOR 
TRANSPORT 

4

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