Prevention of Future Deaths reports · 2023
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 report | 5 Oct 2023 |
|---|---|
| Reference | 2023-0369 |
| Deceased | Jessica Baker |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| 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 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
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.
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.
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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
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