Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0471, written 27 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Aug 2024 |
|---|---|
| Reference | 2024-0471 |
| Deceased | Alfie Tollett |
| Coroner | Deborah Archer |
| Coroner area | Devon, Plymouth and Torbay |
| Category | 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , CEO of Jaguar Land Rover . 1 CORONER I am Deborah Archer , Assistant coroner, for the Coroner area of The County of Devon , Plymouth and Torbay . 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 27th February 2023 I commenced an investigation into the death of Alfie Tollett age 7 . The investigation concluded at the end of the inquest on 16th August 2024 . The conclusion of the inquest was accident . The circumstances of the death were that on 19th February 2023 the Tollett family attended Plymstock Albion Rugby Football club to watch their eldest son play in a friendly training match against Exmouth RFC. The weather was dry and bright with clear blue skies. The club car park was full and club parking attendants were turning cars away. Alfie’s father parked his Kia Niro with all four wheels on the pavement that runs adjacent to the club car park on Wembury Road. Behind the Kia a white VW Transporter van was parked, unattended, with it’s nearside wheels on the pavement and it’s offside wheels on the road. Mr and Mrs Tollett went onto the pitches with Alfie and his little brother. Alfie was playing with his football and some other children at the side of the pitches. The rugby match lasted about an hour, once finished Mr Tollett and his two older sons returned to their car for the boys to change their shoes before they went into the clubhouse. Alfie went to the boot of the Kia to change his boots whilst Mr Tollett crouched on the pavement to untie his eldest son’s boots. Around 11:10 am watch their son play in a match. electric vehicle registration number WF71LCL and his wife was in the front passenger seat. There was a space on the road between the white VW van parked unattended behind Mr Tollett’s Kia and a silver VW van parked further back from the white van. and his wife were attending the rugby club to was driving his wife’s Jaguar ipace slowly pulled onto the pavement so his nearside wheels were on the pavement and his offside wheels were on the road. He used his left hand to select the reverse button to straighten the vehicle up. buttons on the centre consule and relied on feel to select reverse. He looked to his left in preparation to reverse and pressed the accelerator. The Jaguar moved forwards, as did not look down at the 1 reverse had not been selected, failed to notice that the reversing warning alarm had not engaged and collided with the rear of the white VW van causing damage. did not brake and continued to accelerate pushing the white VW van forwards trapping Alfie between the VW van and his father’s Kia. Mr Tollett immediately got into his car and moved it forward to release Alfie who fell to the ground. He then went to Alfie’s aid but sadly Alfie died shortly afterwards with the cause of death being given as blunt force traumatic chest injuries . There has been no prosecution of the driver shortly after this incident . A team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due to Mr Thompson’s death. as he died of natural causes 5 CORONER’S CONCERNS During the course of the inquest the evidence 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. – (1) Although it is accepted that this death was accidental , during the inquest the following information came to light as a result of the investigating police officer giving evidence : (2) There were a number of errors that were made by the driver which caused or contributed to the death . These were Wrongly placing the car in drive instead of reverse Failing to look down at the camera and pressing the button to move forward by touch alone Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed Failing to press the brake at any time . (3 ) However , these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer’s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted to the fact that he had pushed the incorrect button on the 3 button console . 2 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd October 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 – The Tollett family . 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 other 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. 9 27th August 2024 Deborah Archer . 3
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.
rent see ee FAO Deborah Archer Assistant Coroner for the County of Devon, Plymouth and Torbay County Hall Topsham Road Exeter Devon EX2 4QD 22nd October 2024 Case Reference Dear Coroner RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) This is Jaguar Land Rover Limited’s (“JLR”) response to your report made, under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 27th August 2024 (the “Notice”), following the death of Alfie Tollett on 19th February 2023. We would like to express our deepest sympathies to the family and friends of Alfie, following his untimely death. Following receipt of the Notice, JLR has reviewed this incident, and the data from the vehicle involved. Vehicle involved in incident and assistance provided to Police The vehicle involved in the incident was a Jaguar |-Pace, with Vehicle Identification Numbe fn (the “Vehicle”) built on 1st December 2021 and purchased by iron 14th February 2022. Mrs Thompson was the first owner of the Vehicle, which displayed the registration I ENs the wife of HEE «We understand from the Notice, that [ENN as driving the Vehicle when the incident occurred on 19th February 2023. Whilst the Vehicle has been in service JLR has not been informed of any roadside assists, defects or warranty claims. The Telematics Data Request (“TDR”) process is the single route into JLR for all law enforcement data requests in respect of vehicles. The TDR process ensures that the request is made by an individual authorised to make such requests and the relevant legal authorities have been obtained in line with the Data Protection Act 2018. JLR supports law enforcement agencies on a regular basis and provides assistance to aid in investigations. On 28th March 2023, Devon and Cornwall Police informed JLR via the TDR process, of a fatal collision, and asked for supportin retrieving data from the Vehicle’s restraints control module. As part of the TDR process Devon and Cornwall Police supplied a Production Order to JLR which was signed by the Circuit Judge on 14" April 2023. This granted permission for disclosure of the "Full download of the Telematics data control unit relating to Jaguar !-Pace (registration EEE vehicle identification number (VIN) =) containing full event data for Sunday 19" February 2023 between 0001-2359 hours." JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO.: 1672070 LR In Section 3 of the Notice it states that the “team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due tos death.” JLR supported the Police request for data retrieval and JLR representatives extracted the data from the Vehicle on 2nd May 2023 with officers from Devon and Cornwall Police. The extracted data was decoded and then transferred to Devon and Cornwall Police on 19th May 2023. JLR was informed by Devon and Cornwall Police, via email on the same day, that in relation to the Vehicle: “This data willno longerbe required for a criminal prosecution as very sadly the driver of the ipace has died from a suspected heart attack." JLR confirms this is the only request for support received in respect of this matter and no report was requested. JLRat all times fully supported Devon and Cornwall Police request in line with JLR’s standard practices. JLR is a responsible and ethical manufacturer and considers the safety of our products to be the highest priority. Where legally permitted or authorised by the vehicle owner, any allegation of a reported safety concern is investigated thoroughly. Report to prevent future deaths The following concerns are raised in the Notice (reproduced below for ease of reference): “During the course of the inquest the evidence 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. — (1) Although itis accepted that this death was accidental, during the inquest the following information came to light as a result of the investigating police officer giving evidence: (2) There were a number of errors that were made by the driver which caused or contributed to the death. These were e Wrongly placing the car in drive instead of reverse e Failing to look down at the camera and pressing the button to move forward by touch alone e Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged © Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed e Failing to press the brake at any time. (3 ) However, these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive/ reverse other than pressing a button. In the police officer’s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted [REDACTED] to the fact that he had pushed the incorrect button on the 3 button console.” JLR took the following steps in response to the concerns raised in the Report JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER UMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO.: 1672070 Reviewed the Report and considered assistance given to Devon and Cornwall Police. Reviewed and considered all the information that is available in respect of the Vehicle in question (VIN ). © Considered current legal requirements and safety standards applicable to the vehicle in question and this make and model of vehicle in general. e Considered the approach taken by other vehicle manufacturers in respect of the location and operation of the gear transmission control unit. Outcome of steps Section 5 paragraphs 2 and 3 of the Notice states: “errors that were made by the driver which caused or contributed to the death. Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged” “However, these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button. In the police officer’s opinion if there had also beena lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted Mr Thompson to the fact that he had pushed the incorrect button on the 3 button console.” JLR confirms That the Vehicle Certification Agency are an Executive Agency of the Department for Transport and exist to improve vehicle safety and environmental protection by providing robust testing and certification to internationally recognised standards. The gear transmission control unit is assessed for location and use as part of the vehicle certification process. The Jaguar |-Pace is fully certified and meets all applicable United Nations Economic Commission for Europe (UN-ECE) regulated requirements. In addition, the Jaguar |-Pace has achieved the highest safety rating of 5 stars from the European New Car Assessment Programme (Euro NCAP). In reference to the type of gear transmission control unit used in the Jaguar |-Pace, other manufacturers use a similar type of gear selector across many marques and models including, but not limited to: Honda Motor Company Ltd; General Motors Company; Hyundai Motor Group; Ford Motor Company; Tesla Inc; Stellantis NV; Renault SA; Lotus Group Holdings Limited; McLaren Group Limited and Aston Martin Lagonda Global Holdings ple. A photo of the Jaguar I-Pace gear transmission control unit is provided below for ease of reference. JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO.: 1672070 aunt eugaae Figure 1- Photo of Jaguar I-Pace gear transmission control unit with reverse selected This gear transmission control unit is located in the centre console and measures 14.405 cm. Figure 2— Computer Aided Design (CAD) image of Jaguar |-Pace gear transmission control unit with measurements Each button in the gear transmission control unit is clearly labelled, using the same labelling as any other automatic vehicle. As shown, the Reverse (“R”) and Drive (“D”) gear selector buttons are not next to one another. The distance JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM a JAGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO.: 1672070 IX between the centre of the D andR selectors is 6.408 cm, with the button to select Neutral (“N”) located between the D and R gear selector buttons. The Jaguar |-Pace has surface differentiation on the R and Park (“P”) gear selector buttons in order to assist drivers in selecting the relevant gear. For ease of reference, the R gear selector button has a raised tactile cue to distinguish R from the other button selectors. This is in addition to the other visual and auditory alerts, including the selected gear button illuminating (as per UN-ECE Regulation121 - Uniform provisions conce rning the approval of vehicles with regard to the location and identification of hand controls, tell-tales and indicators). The speed threshold, in order to be able to change between ‘Drive’ and ‘Reverse’ driving modes, is 7.7kph. If the driver attempts to change between ‘Drive’ and ‘Reverse’ above this speed there will be no vehicle response i.e. no change in gear selected. A visual indication on the instrument cluster to indicate the gear selected, i.e. R showing on the instrument cluster when reverse gear is selected, is also provided to the driver. Figure 3- Image of the instrument cluster (/_ == vith Park selected taken on 2°4 May 2023 during the vehicle inspection Also, when R is engaged, the rear facing image and 360 degree surround view appears on the infotainment touchscreen (as shown below) which is clearly visible on the centre console above the gear transmission control unit. The infotainment touchscreen is a 10.25 inch LCD display with a resolution of 1920x720 and an aspect ratio of 8:3. JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO.: 1672070 Figure 4 - Image of the infotainment touchscreen of Ecker on 2"? May 2023 during the vehicle inspection with reverse selected There is an Acoustic Vehicle Alert System (AVAS) which is designed to warn pedestrians, near to the Vehicle, of the Vehicle moving in reverse. This sound can be heard within the Vehicle. The minimum requirement forthe AVAS is 47dBs. In the Jaguar |-Pace the soundis designed to be in excess of 47dBs, exceeding the regulatory requirements and can be heard within the passenger cabin. As stated in the Notice, IEEE failed to engage the reverse gear selector button. Had HE selected the reverse gear selector button: The visual indicator in the instrument cluster would have displayed ‘R’; The rear camera would have engaged on the 10.25 inch LCD infotainment touchscreen; The R gear selector button would have illuminated; and The auditory warning would have sounded. The visual indicator on the instrument cluster is in the clear line of sight of the driver. The visual change on the infotainment touchscreen is a clear and obvious indication that you have selected reverse, and the auditory warning can be heard. However, none of these features would have been engaged or showing Rat the time of the incident, as reverse had not beenselected. The D gear selector would have been illuminated and the visual indicator in the instrument cluster would have displayed “D”. Gear selection in the Jaguar I-Pace utilises all of the pertinent human senses; touch, sight and hearing. JLR has reviewed the data extracted from the Vehicle in the 10 seconds prior to the collision of the Jaguar | -Pace with the VW van. This data shows: e The Vehicle did not come to a complete halt at any point; e There was no brake pressure as a result of driver input; JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM 3 4LF, UK | REGISTERE NGLAND AND WALES | COMPANY NO.: 1672070 AGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COV e Inthe 5seconds prior to the collision, the accelerator pedal was depressed at all times; and e Atthe point of collision, the accelerator pedal was depressed to 81%. When observing the driver’s requests made to the vehicle, the accelerator had been depressed to 81% throttle where situationally the brake would normally be pressed to reduce the speed to zero (noting the vehicle accelerated slightly to mount the kerb). JLR would not expect any driver to command 81% throttle for a reverse manoeuvre. In the circumstances of the manoeuvring undertaken by the driver, you would likely see a left steer adjustment just prior to reversal, in order to straighten the vehicle. Without making this left steer adjustment, the driver would travel exactly on the path travelled in the forward direction but in reverse. The data does not show this left steering adjustment, which would normally be made during manoeuvring, in order to straighten the vehicle. Further, the Jaguar |-Pace IGuide (Owners manual) for the Vehicle states, in the section titled “Driving An Electric Vehicle — |Guide Online [OHB]”, “Caution: To maintain control of the vehicle, it is recommended to press the brake pedal during each drive selection.” We thank the Coroner for the time taken to prepare the Notice and for permitting JLR to review the information provided. Upon review of all information and evidence in the case, including the data extracted from the Vehicle and independent vehicle safety testing, it is clear that the current design of the Jaguar |-Pace gear transmission control unit and alert strategy meet all legal requirements for vehicle safety and that no changes are required. JLR will continue to investigate issues of a safety related nature should they arise, as required under the General Product Safety Regulations, and will liaise as necessary with the Driver and Vehicle Standards Agency. Yours sincerely Jaguar Land Rover Limited JLR Abbey Road, Whitley, Coventry, CV3 4LF T. 44 (0)2476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED | REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF, UK | REGISTERED IN ENGLAND AND WALES | COMPANY NO. 1672070
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