Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0164, written 24 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jan 2024 |
|---|---|
| Reference | 2024-0164 |
| Deceased | Brian Chapman |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire and Peterborough |
| Category | 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 Department for Transport 1 CORONER I am Simon MILBURN, Area Coroner for the coroner area of Cambridgeshire and Peterborough 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 14 July 2020 I commenced an investigation into the death of Brian William CHAPMAN aged 76. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that: Medical cause of death – 1a Multiple traumatic injuries; Conclusion – Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH Mr Chapman was a passenger seated on the upper deck of a bus travelling eastbound on the A47 at Wisbech St Mary on 26.06.18. At approximately 0728hrs the bus driver did not react to the presence of an articulated lorry which was undertaking a right hand turn from a haulage depot on the nearside of the carriageway onto the westbound carriageway of the A47. The bus collided at sped with the lorry trailer which was sat across the eastbound carriageway. Extensive damage was caused to both vehicles and sadly Mr Chapman suffered significant and unsurvivable traumatic injuries. His death was confirmed at the scene by a paramedic at 0826hrs. 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) One of the two vehicles involved in the collision was a double decker service bus travelling a scheduled route between Peterborough and Norwich, a distance of approximately 80 miles. The bus was not fitted with passenger seatbelts. I heard evidence that although since 01.10.01 seatbelts are required to be fitted in all new buses(this vehicle was on a ‘63’ plate’) there is an exemption where such vehicles are designed for urban use with standing passengers. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Whilst this particular route required the bus to travel from/to and stop off in 5-6 urban centres the majority of the journey took place on a major A route through rural areas. The speed of the bus at the point of collision was approximately 53mph. Both the bus driver and an upper deck passenger were killed in the collision. Whilst there was no evidence that either death would have been prevented by the wearing of seatbelts a number of other passengers were injured in the collision. I am concerned where buses are undertaking journeys such as this through predominantly rural locations and subject to the national speed limit without seatbelts being required there is an obvious risk of death to passengers if collisions occur, particularly at high speed. 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 March 25, 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 Family of Family of Mr Chapman Legal Representatives for Brett Transport Legal Representatives for First Bus Legal Representatives for 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: 24/01/2024 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Mr Simon Milburn Area Coroner for Cambridgeshire and Peterborough Lawrence Court Princes Street Huntingdon PE29 3PA 21 March 2024 Dear Mr Milburn, Thank you for your Regulation 28 Report to Prevent Future Deaths dated 24 January, sent to the Department for Transport following the conclusion of your inquest into the death of Brian William Chapman. I am sorry to hear of the tragic death of Mr Chapman, for which I offer my sincere condolences to his family and friends. Travel by bus and coach is one of the safest modes of road transport in Great Britain. That said, the Department is committed to improving safety for all bus passengers using appropriate vehicle construction standards and ensuring the safe operation of vehicles. Our national regulations set the minimum construction standards for new road vehicles and utilise a number of specifications that are harmonised with the wider international community. Since 2001, seat belts have been required for each forward and rearward facing seat in all new buses. The only exemption from the mandatory requirement to fit seatbelts is for buses designed to carry standing passengers. These tend to travel at moderate speeds on urban routes and are relatively heavy when compared to most of the adjacent traffic. This means that seat belts would have only a very limited road safety benefit and are not required to ensure comparable levels of protection between seated and standing passengers. Once a bus is approved for use there are no specific regulations to restrict the type of roads it can use and for standard bus services it is for the operator to choose the type of vehicle used to provide a given service, and this should take account of the type of intended operation. Exceptions to this cover contracted or tendered services where the local transport authority can specify the type of vehicles or equipment to be used, which could include requiring only vehicles fitted with seat belts. Traffic Commissioners are responsible for licensing and regulation of those who operate buses and the registration of most bus services. On the request of a local transport authority, a traffic commissioner can consider the potential use of Traffic Regulation Conditions (TRCs) to prevent danger to road users. It would be for the individual traffic commissioners to determine whether their powers could extend to the use of a TRC to restrict certain buses from particular roads. Overall, we believe the existing regulatory framework is appropriate as it harmonises vehicle construction with the wider international community and provides proportionate safeguards whilst ensuring the legislative landscape is sufficiently flexible to meet the needs of the local community. This ensures the economic viability and sustainability of bus services, which in turn supports social inclusion and the local economy, particularly in rural areas. Finally, my officials will write immediately to the CPT, the trade body which represents bus and coach operators, highlighting the importance for their members in selecting appropriate vehicles based on the type of bus service operated, including full consideration of using only vehicles fitted with seat belts. At that same time they will also write to the Office of the Traffic Commissioner to raise awareness of this issue. Yours sincerely, The Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT
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