Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0157, written 20 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2024 |
|---|---|
| Reference | 2024-0157 |
| Deceased | Ellie Hunt |
| Coroner | Alison Norton |
| Coroner area | North Yorkshire and York |
| Category | Child Death (from 2015) · Road (Highways Safety) 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Rt Hon Mark Harper MP, Department for Transport 1 CORONER I am Alison Norton, Assistant coroner for the coroner area of York and North Yorkshire. 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 31 August 2021 I commenced an investigation into the death of Ellie Louise Frances HUNT aged 9. The investigation concluded at the end of the inquest on 08 March 2024. The conclusion of the inquest was that: On the 24th August 2021, Ellie Louise Frances Hunt was a travelling in the rear of a motorhome on the A64, Barton Hill. The front near side tyre unexpectedly deflated and the motorhome collided with a stationery vehicle. Ellie Louise Frances Hunt suffered multiple injuries. Her injuries were not survivable. Her death was confirmed at the scene of the collision, namely the A64, Barton Hill, at 20.08 on the 24th August 2021. 4 CIRCUMSTANCES OF THE DEATH On the 24th August 2021, Ellie Louise Frances Hunt was a travelling in the rear living area of a motorhome vehicle, on the A64 Barton Hill, when the front near side tyre of the vehicle deflated, leading to a collision with a stationery vehicle. Ellie Louise Frances Hunt died instantaneously due to her multiple injuries. The vehicle had been converted into a motorhome, having originally been a works van. There were no seatbelts in the rear of the vehicle. 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: (brief summary of matters of concern) Evidence given during the inquest indicated that there is no legal obligation for seat belts to be fitted in the rear areas of motorhomes, for passengers to use when the vehicle is in motion. Whilst it was not possible to establish whether Ellie Louise Frances Hunt would have survived the impact if she had been wearing a seatbelt, as a wider point of public safety, I am concerned that adults and children over three years can travel in the rear areas of motorhomes without restraint, and that in doing so, this may create a risk to life. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 OFFICIAL -- SENSITIVE OFFICIAL SENSITIVE 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 May 15, 2024. 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 have also sent it to Chief Constable for North Yorkshire, Rotherham LSCB who may find it useful or of interest. 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: 20th March 2024 Alison Norton Assistant coroner for the coroner area of York and North Yorkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021 OFFICIAL -- SENSITIVE OFFICIAL SENSITIVE
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.
Alison Norton
Assistant Coroner
Office of HM Senior Coroner for North Yorkshire &
York
The Coroners Court
3 Racecourse Lane
Northallerton
DL7 8QZ
From the Secretary of State
The Rt Hon Mark Harper MP
Great Minster House
33 Horseferry Road
London
SW1P 4DR
14 May 2024
Dear Ms Norton,
Thank you for your Regulation 28 Reports to Prevent Future Deaths dated 20
March, sent to the Department for Transport following the conclusion of your
inquest into the deaths of Shirley Ann Hunt and Ellie Louise Frances Hunt. I
am sorry to hear of the tragic deaths of Mrs Hunt and Ms Hunt, for which I
offer my sincere condolences to their family and friends.
You found that the evidence considered during your inquest raised concern
that adults and children over three years of age can travel in the
accommodation area of a motor caravan without restraint, and in doing so,
this may create a risk to life.
Fortunately, there are relatively few casualties amongst occupants of motor
caravans in Great Britain, but the Department is committed to improving
safety for all road users with appropriate vehicle construction standards and
ensuring the safe operation of vehicles.
From 29 April 2012, newly registered motor caravans have required all seats
intended for use when the vehicle is travelling, irrespective of whether they
are fitted to the accommodation area or elsewhere in the vehicle, to be fitted
with seat belts. Seats which are not suitable for use whilst travelling and not
fitted with seat belts must be clearly identified to users by means of a
pictogram or a sign with appropriate text.
Motor caravans first used before 29 April 2012 and any vehicles converted to
a motor caravan after registration are subject to different rules, and only
require mandatory seat belts for the driver and front passenger seats. There
are no regulations prohibiting the fitment of additional seat belts where more
passengers are intended for transport than can be accommodated in front
seats.
Vehicles converted after registration are typically those which are re-
purposed and converted following an initial service life as a commercial
vehicle. We believe this to be the category of vehicle that the Hunt family
were travelling in at the time of the collision.
Although it is not illegal to travel unrestrained in the accommodation area of a
motor caravan where no seat belts are fitted, the Department has published
guidance at the following link which advises that passengers are safest in a
forward or rearward facing seat equipped with a three-point seat belt.
www.gov.uk/government/publications/carriage-of-passengers-in-campervans
Overall, I believe the existing regulatory framework is proportionate as it
introduced enhanced requirements for new motor caravans from 2012 and
provides sufficient in-use provision to cover the broad range and age of motor
caravans operating on our roads.
However, I have asked my officials to consider what further options might be
possible and appropriate to help prevent similar occurrences in future.
Yours sincerely,
The Rt Hon Mark Harper MP
SECRETARY OF STATE FOR TRANSPORT
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