Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0623, written 13 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Nov 2024 |
|---|---|
| Reference | 2024-0623 |
| Deceased | Andrew Howat |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Kingkabs Wheatsheaf Garage Parkgate Road Cheater CH1 6JS CORONER 1 I am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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 the 16th of October 2022 I commenced an investigation into the death of Andrew Howat (DOB 29.01.82 DOD 15.10.22). The investigation concluded at the end of the inquest on the 12th of November 2024. The cause of death was recorded as being due to 1(a) Multiple Injuries and the conclusion of the inquest was that the death was due to a road traffic collision 4 CIRCUMSTANCES OF THE DEATH On the 15th of December 2022, the deceased was collected by a Kingkabs taxi from a Chester Hotel. He was intoxicated at the time and as a result of disruptive behaviour the driver felt it unsafe to continue the journey and dropped him at a petrol station. Another taxi was ordered from the same firm, and he was collected for his onward journey home. Again as a result of his disruptive behaviour the driver was not prepared to continue the journey without full payment of the fare and stopped in a layby on the A483 dual carriageway in an unlit area with no means by which a pedestrian could easily leave the area (notwithstanding that there was a junction approximately 400 metres away which would have been a safe place to discharge the passenger). When the deceased got out of the taxi, the drive left him in an unsafe location and no contact was made with the police by the firm to advise them of the potential risk to both the deceased and other traffic. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – Oral testimony was given by a representative of Kingkabs that appropriate training was being provided to drivers seeking to balance the risk to themselves with their duty of care to their passengers, however the taxi driver stated in his evidence that if similar circumstances arose, he would do nothing different and would still be prepared to leave a passenger in an unsafe location. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | Furthermore, the firm’s representative advised that usual practice would be to contact the police in circumstances such as these, but this was not done on this occasion and no evidence or documentation was available to corroborate that staff were being trained in respect of this protocol. 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 8th of January 2025 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 Family of the Deceased and to the Chief Coroner. 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 13th November 2024 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
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.
John Adrian Gittins Senior Coroner for North Wales (East & Central) Coroner’s Office Wynnstay Road, Ruthin, Wales, LL15 1YN Sent via Email to: 7th January 2025 Subject: Response to Regulation 28 Report to Prevent Future Deaths Dear Mr Gittins, Thank you for your Regulation 28 Prevention of Deaths report dated 13th November 2024 regarding the tragic death of Andrew Howat. First and foremost, we wish to extend our sincere condolences to Mr Howat’s family and loved ones. As a business we remain committed to ensuring the highest standards and have carefully reviewed the matters of concern highlighted in your report, wishing to respectfully address the two key points raised: (a) the driver’s adherence to training and guidance; and (b) the failure to contact the police on 999 during the incident. Driver Training The driver’s decision to discharge the passenger at an unsafe location is deeply regrettable and we acknowledge that their actions on this occasion fell short of the standards we would expect. While drivers are trained to balance their own safety with their duty of care to passengers, we recognise that this tragic outcome signals a need to reinforce and clarify our procedures with drivers. To further enhance this message, we have updated the “DR18 Driver Information & Advice” document, issued to all drivers during onboarding. Specifically, two new sections were added (Legal Duty of Care, Incident Procedures: Breakdown, Accident & Violence) and another strengthened (Managing Confrontation & Violent Situations) to provide clearer guidance on resolving confrontation, emphasising duty-of-care and the importance of safe decision-making in difficult circumstances. On the 3rd January 2025, using our document sharing feature, we have updated all our drivers with the enhanced clearer guidance. As a Company we have taken this opportunity to reach out to all our c. 1,300 drivers covering not just KingKabs but to the wider group, ensuring consistency and firm commitment in our message. Police Contact Procedure was a manager at KingKabs and was working on the evening of the incident. While an attempt was made by understand that this was not successfully completed. Whilst he overheard a colleague say there had been a serious accident in the same location. to call 101 (non-emergency services), we was on hold with 101, assumed it was linked with his call, hung up immediately and dialled 999. On review, the process followed by procedures within it could be made more robust. As such and in tandem with the driver was not adequately documented and the KingKabs Limited, Wheatsheaf Garage, Parkgate Road, Saughall, Chester CH1 6JS Bookings: 01244 34 34 34 | Admin: 01244 852 597 | Email: info@kingkabs.co.uk Company No.: 03623784 | VAT No.: 477 1632 29 procedures, we have documented a new set of ‘Driver Incident Procedures’ in “CC002 Call Centre Procedures” document for call centre staff, which provides clear and detailed guidance on when and how to escalate incidents to the police and other emergency services. The updated version of CC002 has been sent to all staff on 3rd January 2025. To demonstrate the proactive measures we have taken, we attach relevant excerpts from the updated “DR18 Driver Information & Advice” and “CC002 Call Centre Procedures” documents. We have not submitted the full documents as they contain commercially sensitive information. We respectfully request that these excerpts be redacted also for commercial privacy purposes before any wider publication. We are committed to talking all necessary steps to ensure the safety of our passengers and to address the concerns raised in your report. Should you require any further details or clarification, please do not hesitate to contact me directly at . Yours Sincerely, Regional General Manager (Northwest) For and on behalf of KingKabs Limited. KingKabs Limited, Wheatsheaf Garage, Parkgate Road, Saughall, Chester CH1 6JS Bookings: 01244 34 34 34 | Admin: 01244 852 597 | Email: info@kingkabs.co.uk Company No.: 03623784 | VAT No.: 477 1632 29
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