Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0648, written 26 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 | 26 Nov 2024 |
|---|---|
| Reference | 2024-0648 |
| Deceased | Jon-Paul Prigent |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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 Secretary of State for Transport 2. Driving Standards Agency (DVSA) 3. The National Farmers Union 4. The Agricultural Engineers Association 5. The British Agricultural and Garden Machinery Association 6. The Health and Safety Executive 1 CORONER I am Peter Nieto, senior coroner for the coroner area of Derby and Derbyshire. 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 July 2020 I commenced an investigation into the death of Mr Jon-Paul PRIGENT aged 47. The investigation concluded at the end of the inquest on 15 November 2024. The conclusion of the inquest was that: - Jon's death was due to the decoupling of a laden trailer from its towing tractor. It is unlikely that his death would have occurred if the hitch and coupling components had been checked to a reasonable standard. 4 CIRCUMSTANCES OF THE DEATH Jon died on 30 July 2020 at Station Lane Old Whittington near Chesterfield, due to a trailer containing soil overturning on to the car he was in. Jon was sitting in the passenger seat preparing to give a driving lesson to his daughter. The trailer had decoupled from the tractor it was hitched to, and the trailer descended down the hill hitting a wall which caused it to overturn. The weight of the trailer put Jon into a compressed position and led to asphyxiation. The tractor and trailer belonged to and was used by a skip hire company. On 30 July they were being used to transport soil from the business premises and yard to the family home for use on land surrounding the property. The journey was along Station Lane, a public highway. The trailer decoupled from the tractor as the tractor went over a speed bump. That section of Station Lane is also on a hill. On the evidence the decoupling probably occurred due to a combination of factors: - - Wear of the coupling components: the towing hook, the hitch ring was warm to below its minimum thickness, and there was a gap between the location of the tip of the towing hook and the keeper plate. - The trailer was overloaded. It was manufactured for a maximum load of ten tonnes but the soil it was loaded with weighed thirteen point eight tonnes. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 - The soil was unevenly distributed and weighted more to the rear of the trailer adversely affecting the trailer's centre of gravity. - As the hitch coupling passed over the speed bump a bigger gap opened up for the hitch ring to pass between the tow hook and keeper plate. - On inspection after the incident it was noted that the tip of the tow hook was missing. Whether it had been missing before the decoupling or was sheared-off during the decoupling cannot be established. - The owner and user of the tractor and trailer was required to check their roadworthiness including the hitch and coupling components before each day of use. It is unlikely that a check that day, or recent checks, had been adequate because had those checks been good enough, the degree of component wear would have been noted, and appropriate corrective measures should have been taken. Independent professional vehicle testing is not legally required for tractors and trailers used for agricultural purposes. The driver of the tractor stated that had he seen the degree of wear on the components he would not have taken the tractor trailer on to the road on 30 July. - The tractor and trailer did not have safety features to prevent decoupling because legislation does not require these for tractors which are driven at below twenty-five miles per hour. 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: - 1. Tractors and trailers driven on roads for ‘agricultural purposes’ are not subject to periodic independent vehicle testing. This places the responsibility for checking roadworthiness on the user which is clearly dependent on the diligence and competence of the user. It is therefore highly likely that some tractors and trailers are being driven on roads for ‘agricultural purposes’ in unroadworthy and unsafe condition, as was clear in Mr Prigent’s inquest. 2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling (e.g. a safety chain, or dual safe braking system). Therefore, if decoupling occurs there is nothing to prevent independent and uncontrolled travel of the trailer. 3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling. 4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another. 5. At inquest I heard expert evidence on the above points, and that other nations, particularly in the European Union, have introduced comparatively robust legislation regarding testing and safety measures/fittings. 6. At inquest I heard evidence that the fitting of safety features to prevent decoupling is relatively low cost and that there have been previous voluntary schemes to CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 encourage and incentivise these measures. 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 January 21, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- I have also sent it to: - Derbyshire police road traffic team, and The National Police Chiefs' Council lead for Roads Policing, Chief Constable of Sussex Police, 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: 26 November 2024 Peter Nieto CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 Senior coroner for Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
4 responses 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.
AEA & BAGMA response to Report to Prevent Future Deaths in the case of Mr Jon-Paul Prigent The Agricultural Engineers Associa(cid:2462)on (AEA) and the Bri(cid:2462)sh Agricultural and Garden Machinery Associa(cid:2462)on (BAGMA) welcome the opportunity to respond to the coroner’s report on this important issue. BAGMA is owned by the AEA and we work together closely on industry-wide concerns such as this, so we are providing a joint response. This response is supported by the members of both organisa(cid:2462)ons. Exis(cid:2462)ng products and services Before turning to future ac(cid:2462)ons, we wish to highlight our exis(cid:2462)ng products and services that are aimed at improving the safety of tractors and trailers used on UK roads. Given its importance to the safety record of our members’ products, this topic has been a big focus of our work over many years. While there is no requirement for the roadworthiness of tractors and trailers to be independently tested, BAGMA does operate a voluntary scheme. The Agricultural Tractor- Trailer Scheme (ATTS) incorporates both roadworthiness inspec(cid:2462)on and brake performance tes(cid:2462)ng in one package. In our view, the ATTS is the only tes(cid:2462)ng regime that provides a robust assessment of the roadworthiness of agricultural tractors and trailers as no other scheme incorporates brake performance tes(cid:2462)ng alongside roadworthiness inspec(cid:2462)on. Applicable to tractors, trailers, trailed implements or self-propelled agricultural machines, the ATTS tes(cid:2462)ng can be provided by experienced dealer technicians, larger farm and fleet users that have their own servicing personnel or independent service engineers. Each technician undertakes a 2-day training course, which includes both prac(cid:2462)cal and ‘class-room’ training which concludes with a wri(cid:130)en examina(cid:2462)on. Every ATTS technician must a(cid:130)end refresher training a(cid:91)er 5 years to ensure they keep abreast of tes(cid:2462)ng and inspec(cid:2462)on procedures and legal requirements. Each trailer/trailed implement inspected under the ATTS is subject to a 37-point inspec(cid:2462)on, based on HGV annual test inspec(cid:2462)on criteria, complemented by a brake performance test. During vehicle inspec(cid:2462)on and tes(cid:2462)ng the technician completes an inspec(cid:2462)on record form that includes their own unique iden(cid:2462)fica(cid:2462)on number, to ensure traceability and recordability. The ATTS procedure will iden(cid:2462)fy and assess any tractor or trailer defects which need to be addressed: it is then up to the vehicle owner to have these rec(cid:2462)fied. Recognising that much of the responsibility for ensuring the safety of tractor and trailer braking rests with the user and the service technicians that support them, the AEA has produced detailed guidance on both the legal requirements and the prac(cid:2462)cal steps needed to ensure that braking systems are safe and well maintained. Our Look Behind You guide was first published in 2010 and was updated in 2020, incorpora(cid:2462)ng interac(cid:2462)ve elements, such as short videos and anima(cid:2462)ons, helping to improve understanding of key aspects of safety. The guide has been widely distributed through machinery dealers and is also available online at: h(cid:130)ps://aea.uk.com/look-behind-you/. It was supported by most of the main suppliers of tractors and agricultural trailers to the UK market. Roadworthiness Tes(cid:2462)ng Turning to future ac(cid:2462)ons, as the coroner’s report notes, there is currently no requirement for independent roadworthiness tes(cid:2462)ng for agricultural tractors and trailers, where they are solely used for agricultural ac(cid:2462)vi(cid:2462)es. The AEA and BAGMA have long supported calls for such a regime to be introduced, par(cid:2462)cularly for the larger and heavier vehicles that are now commonplace. While any decision on making such a scheme compulsory must be made by the Secretary of State for Transport, AEA and BAGMA would be happy to offer to take the lead in administering a scheme. In our view, the ATTS referred to above could form the basis of a mandatory tractor and trailer roadworthiness tes(cid:2462)ng scheme. As indicated above, we already have training programmes in place to assess and approve service technicians to be able to deliver the required tes(cid:2462)ng, with periodic refresher training required. We would have no difficulty in expanding that training programme to cover the larger number of approved technicians that would be required for a compulsory scheme. Furthermore, the AEA already has experience of administering a similar tes(cid:2462)ng scheme through the Na(cid:2462)onal Sprayer Tes(cid:2462)ng Scheme (NSTS), which we run on behalf of government. This requires all crop sprayers in use by farms, hor(cid:2462)cultural growers and amenity providers to be tested periodically. As with the ATTS, inspectors are trained and approved by the AEA and all tests carried out are recorded on a na(cid:2462)onal database, administered by the AEA, with cer(cid:2462)ficates issued to machinery owners as proof of compliance. We believe that the requirements of a tractor and trailer roadworthiness scheme would be similar to those of the NSTS. Therefore, we believe that our exis(cid:2462)ng experience of both tractor and trailer tes(cid:2462)ng and administering a similar scheme, means that the AEA and BAGMA would be well placed to take on the administra(cid:2462)on of a new scheme, should government choose to introduce one. We would, of course, be happy to work with the Department for Transport and the DVSA on the details. Some ini(cid:2462)al funding might be required to support the development of a scheme but once it is up and running, any costs should be covered by fees charged to carry out tes(cid:2462)ng. Changes to legisla(cid:2462)on While roadworthiness tes(cid:2462)ng would go a long way to addressing the concerns iden(cid:2462)fied in this case, the coroner’s report also iden(cid:2462)fies deficiencies in the current legisla(cid:2462)on around use of agricultural tractors and trailers on the road. The AEA and BAGMA would support changes to legisla(cid:2462)on, in par(cid:2462)cular to address the current lack of any requirement for either ‘Breakaway Failsafe’ trailer brakes or a secondary coupling (such as a safety chain) between the towed and towing vehicle, if the vehicles don’t exceed 40 km/h. Of course, any decision on amendments to legisla(cid:2462)on rests with the Secretary of State for Transport. However, the AEA and BAGMA stand ready to provide any advice required to inform that decision. We believe that the proposed changes could be achieved with a rela(cid:2462)vely simple amendment to the Road Vehicles (Construc(cid:2236)on and Use) Regula(cid:2236)ons 1986. Ar(cid:2462)cle 86a of those regula(cid:2462)ons only currently applies to vehicles travelling above 40km/h (approximately 25mph). We suggest that this should be expanded to include vehicles travelling below that speed with a gross weight above a certain level. This could be modelled on regula(cid:2462)ons in the Republic of Ireland, which use 5 tonnes as the cut off but we have no par(cid:2462)cular view on whether that would be the most appropriate limit in the UK circumstances. The Irish road vehicle legisla(cid:2462)on was historically very similar to GB legisla(cid:2462)on but was revised in January 2016 to address concerns similar to those expressed by the coroner. Several other EU countries have also updated their na(cid:2462)onal legisla(cid:2462)on, so could provide alterna(cid:2462)ve approaches for considera(cid:2462)on. While there would be some cost involved in ensuring that exis(cid:2462)ng trailers were able to comply with any change to the rules, we believe that these would not be par(cid:2462)cularly onerous. In some cases, the fi(cid:2478)ng of a secondary coupling is all that would be required, which can be done at low cost. The Irish market is typically supplied from the UK, so tractor and trailer manufacturers are already used to providing similar couplings there. In other cases, kits are available to convert trailer braking systems into ‘breakaway failsafe’ systems for below £1,000. These can be installed in a farm workshop. Most new trailers already incorporate such braking systems, so would not require and further modifica(cid:2462)on. Therefore, we believe that the impact of any changes to the legisla(cid:2462)on would be limited. Conclusion We would support any proposals for change from the Department for Transport in the two areas discussed above. We note that for the changes to achieve the safety improvements we are hoping for, there would also need to be effec(cid:2462)ve enforcement of the requirements. That hasn’t always been the case in the past; indeed, the case referred to in the coroner’s report shows that exis(cid:2462)ng requirements aren’t followed by all users. Nevertheless, we believe that the changes proposed would certainly reduce the likelihood of serious accidents taking place in future.
• Department
for Transport
Peter Nieto
Senior Coroner for Derby and Derbyshire
Coroner's Court,
Town Hall,
Chesterfield,
S40 1LP
From the Parliamentary Under
Secretary of State
Great Minster House
33 Horseferry Road
London
SW1P4DR
Tel: 0300 330 3000
E-Mail:
Web site: www.gov.uk/dft
Our Ref:
It February 2025
Dear Mr Nieto,
Thank you for your report of 5 December 2024 made under the Coroners and
Justice Act 2009 and the Coroners (Investigations) Regulations 2013,
following the inquest into the death of Mr Jon-Paul Prigent. I am deeply
saddened to hear of Mr Prigent's death and offer my sincere condolences to
his family and friends.
My Department is strongly committed to improving the safety ofall road
users. Relevant regulation includes the requirement for all new vehicles to be
approved to demonstrate that they comply with a range of technical
requirements before they can be sold. The relevant manufacturer
requirements for the type-approval of new agricultural tractors are set out in
assimilated Regulation (EU) No 167/2013. Once a vehicle enters service the
relevant requirements are contained in the Road Vehicles (Construction and
Use) Regulations 1986.
My Department conducted a consultation in 2016 on introducing
roadworthiness testing for fast tractors used for commercial haulage. As a
result, agricultural tractors capable of a speed over 40km/h (approximately
25mph) being used for commercial haulage were brought into scope of the
Motor Vehicles (Tests) Regulations 1981, therefore requiring them to be
subject to annual roadworthiness testing. At the time, it was decided that it
would not be proportionate to bring slower speed agricultural tractors in scope
of annual roadworthiness testing given their use on roads is limited in
comparison with other vehicles.
Our road collision statistics show that, over the last ten years, the number of
incidents involving an agricultural vehicle where someone was killed has
remained relatively stable.
This is despite a slight increase in the number of agricultural vehicles
registered for use on our roads over the same period. In the 10 years from
2014 to 2023, in GB there was an average of nine deaths a year involving
tractors in which a trailer may have been in use, and there is no evidence on
an increasing trend in these fatalities. During the same time period there was
an average of 323,000 tractors in GB, including the faster ones subject to
roadworthiness testing, licensed for use on the road.
It is a legal requirement that all vehicles used on the road are maintained in a
roadworthy condition at all times. Further, vehicles should not be loaded
beyond their capacity. As part of ensuring compliance, the Driver and Vehicle
Standards Agency ("DVSA") conducts roadside checks throughout the road
network. Where non-compliance is evident, this can result in a vehicle being
prohibited until the weight is reduced or the defect rectified. In addition to
prohibitions, DVSA also impose fixed penalties on the drivers of such vehicles
which range from £50 to £300 depending on the severity of the offence.
Alternatively, more severe cases can be reported for criminal prosecution.
The DVSA publishes guidance on both maintaining roadworthiness and
vehicle loading and these are available at the links provided below:
www.gov.uk/government/publications/guide-to-maintaining
roadworthiness/guide-to-maintaining-roadworthiness-commercial-goods-and
passenger-carrying-vehicles
www. gov. u k/g u idance/secu ri ng..:loads-on-hgvs-and-goods-veh icles
The general principles of these guides equally apply to light goods and
passenger vehicles below the operator licensing thresholds and for vehicles
that are otherwise exempt (such as agricultural vehicles and trailers).
.
.
In addition, DVSA also publish the Categorisation of Defects manual which is
made available so that vehicle owners, operators and drivers can become
more aware of DVSA's standards and what will be done should problems be
found. Part 1 of the manual is intended for heavy goods and public service
vehicles and may also be used for agricultural motor vehicles, trailers and
trailed appliances.
https://assets. publishing.service.gov.uk/media/6748955424108edc3c8cebde/
catego risation-of-veh icl e-defects. pdf
The Health & Safety Executive provides guidance regarding safe workplace
transport in the agricultural sector, which can be accessed at:
www.hse.gov.uk/agriculture/topics/machinery/farm-vehicles-1.htm
OFFICIAL
Further, to assist owners in maintaining their agricultural trailers, a well
established private sector voluntary scheme, Tilly Pass, provides for the
inspection and service of agricultural machinery to British Standard
14200:2023 on the maintenance of machinery. Details can be found at:
www.tillypass.co. uk/
In view of your report, I will instruct my officials to examine what more could
be done to ensure the roadworthiness of tractors, trailers and coupling
devices. Additionally, to help promote good maintenance of agricultural
vehicles I have asked my officials to investigat� how best to raise awareness
of the DVSA's published guidance on maintaining roadworthiness and vehicle
loading, as well as of the existing voluntary trailer maintenance scheme. My
officials will consider how best this information can be communicated to
operators of agricultural vehicles.
The Department will continue to monitor the effectiveness of vehicle safety
regulations to identify any potential amendments.
Once again, I would like to express my condolences to the f.riends and family
of Mr Prigent.
Best wishes,
MINISTER FOR THE FUTURE OF ROADS
OFFICIAL
Health and Safety Executive Engagement & Policy Division Agriculture, Vulnerable Workers, Waste & Recycling Unit Hornbeam House Electra Way Crewe CW1 6GJ http://www.hse.gov.uk/ Head of Unit Peter Nieto Senior Coroner for Derby and Derbyshire Derby Coroner’s Office and Courts St Katherine’s House, St Mary’s Wharf Mansfield Road Derby DE1 3TQ 20th January 2025 Reply sent by email only to: Dear Mr Nieto Inquest into the death of Mr Jon-Paul Prigent – Regulation 28 report. Thank you for your email and associated Regulation 28 report touching on the death of Mr Jon-Paul Prigent, which was sent to the Health and Safety Executive (HSE) on 3rd December 2024. I am the HSE Inspector with the lead for operational policy in relation to controlling health and safety risks associated with agricultural machinery including tractors and trailers, and have been asked to reply to you on the matters that you raise. It is understood that the tractor and trailer involved in this fatality were not being used for agricultural purposes, but rather by a skip hire company to transport soil. We note your report was sent to a number of bodies with an interest in this issue. This response will address matters that are within HSE’s areas of responsibility as a regulator, and highlight where matters are more appropriately addressed by other organisations. Introduction and background Before addressing your concerns directly, it may help for me to outline HSE’s role and areas of responsibility in relation to this matter. HSE are Britain’s national regulator for workplace health and safety, this includes use of work equipment such as vehicles in the workplace, but would not routinely include use of vehicles on public roads. Vehicle use, condition and maintenance cross over two areas of legislation: road traffic, which is enforced by the Driver & Vehicle Standards Agency (DVSA) and police forces, and workplace safety which is enforced by HSE and local authorities. In terms of controlling workplace risk, health and safety legislation is goal setting in its nature, rather than prescriptive, but still requires dutyholders / businesses to meet certain legal standards. The Health and Safety at Work etc. Act 1974 (HSWA) and Regulations made under it require employers to assess the risk from work operations, including use and maintenance of vehicles in the workplace, and provide control measures to reduce these risks, so far as is reasonably practicable. As well as the HWSA which requires businesses to do all that is reasonably practicable to control work-related risk, health and safety regulations also set out legal duties on businesses. The health and safety regulations covering the use of work equipment such as tractors and trailers is the Provision and Use of Work Equipment Regulations 1998 (PUWER) – a copy of the regulations is available here: https://www.legislation.gov.uk/uksi/1998/2306/contents. PUWER contains a number of legal duties which it places on the dutyholder. PUWER places a legal duty on all relevant dutyholders to select work equipment that is suitable for the task for which it is used. Work equipment must be used for suitable operations and under suitable conditions. Therefore, when selecting vehicles to move or transport loads, the most appropriate vehicle / trailer should be selected, and the limits of any vehicle e.g maximum loads, should not be exceeded. PUWER also requires that all work equipment is maintained in an efficient state, in efficient working order and in good repair. The regulations also place duties on businesses to ensure that work equipment which is exposed to conditions causing deterioration liable to result in dangerous situations, is inspected at suitable intervals. Inspections made under PUWER should be recorded by the dutyholder. Any piece of work equipment found not to be maintained in a safe condition should not be used until the defect has been remedied. To help dutyholders comply with their legal duties regarding the use of agricultural machinery, including tractors and trailers, HSE has published a range of guidance which is freely available to download from our website. Guidance includes, but is not limited to: • • • “Using tractors safely” available at: https://www.hse.gov.uk/pubns/indg185.pdf “Working safely with agricultural machinery” available at: https://www.hse.gov.uk/pubns/indg241.pdf “Using machines safely” available at: https://www.hse.gov.uk/agriculture/topics/machinery/safe-use-1.htm These are just some examples of the guidance freely available to users of agricultural machinery which raise the importance of using suitable equipment for the task at hand, putting in place a safe system of work, properly checking and maintaining trailers to manufacturers specifications (including braking systems and hitch / attachment points), not overloading trailers, the increased risk when using machinery on slopes, operator training, and the underlying importance of planning and risk assessments. The above guidance has been available to those using agricultural machinery for many years and contains sufficient information to enable dutyholders to use agricultural machinery safely. Those with legal duties under health and safety legislation should be aware of their duties. The Management of Health and Safety at Work Regulations 1999 (MHWR) require businesses to appoint one or more competent persons to assist them in complying with their legal duties under health and safety legislation; this would include legal duties under PUWER. The robust health and safety legislative framework and associated guidance is in place to both require and enable those using agricultural machinery to do so safely. All of this information is freely available via HSE’s website. Your concerns 2 You raise the following MATTERS OF CONCERN in your report. I shall address these in turn, set against the background information already provided above: 1. Tractors and trailers driven on roads for “agricultural purposes” are not subject to periodic independent vehicle testing. As outlined, health and safety legislation does require businesses to select, inspect and maintain work equipment including tractors and trailers to ensure they are suitable for the tasks being carried out and safe for use. Where work equipment is not safe to use it should be taken out of use until repaired. Periodic independent vehicle testing requirements specifically for tractors and trailers driven on the public road would be a matter for other organisations such as the DVSA to consider. 2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling. HSE do not enforce road safety legislation, therefore this matter would be for other organisations such as the DVSA to consider. 3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling. Basic hitch hook and ring coupling systems for tractors and trailers can be appropriate for the farm workplace provided they are suitably maintained, and the vehicles are appropriately used by trained persons. The use of such systems for tractors and trailers on the public road would be a matter for other organisations such as the DVSA to consider. 4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another. It is true that farm machinery such as tractors and trailers can be much larger and more complex than years ago. All farm machinery should be maintained to the manufacturers specifications and used in accordance with instructions in the manufacturer’s handbook. It is for those using agricultural machinery to assess how it will be used, including the environment and put in place suitable control measures to ensure that people are kept safe. Use of agricultural vehicles on public roads would not be a matter for HSE. 5. At inquest I heard expert evidence on the above points, and that other nations, introduced comparatively robust in the European Union, have particularly legislation regarding testing and safety measures/fittings. With regards to workplace use, the health and safety legislative framework and associated guidance is sufficient and clear in its requirement to use equipment suitable for the task that is maintained in a safe condition. The duty rests with businesses to ensure that where appropriate they comply with legislation such as HSWA, PUWER and MHWR. The legislation has been in place for many years and the requirements are well-known. There are a number of organisations, schemes and providers currently able to carry out 3 inspection of farm equipment, including farm vehicles. In addition, the manufacturers of the equipment may also offer inspection services. 6. At inquest I heard evidence that the fitting of safety features to prevent decoupling is relatively low cost and that there have been previous voluntary schemes to encourage and incentivise these measures. Health and safety legislation currently requires farmers to take reasonably practicable measures to control significant risk. Using suitable vehicles within their design parameters reduces the likelihood of unsafe conditions. Dutyholders should assess the risk from the use of agricultural machinery and if there is an increased risk of trailers decoupling from tractors resulting in risk to persons, farmers should take reasonably practicable steps to prevent such an occurrence. It is for the dutyholder to assess the risk and take appropriate steps to ensure that risk is controlled. Conclusion While many of the MATTERS OF CONCERN raised are more appropriately addressed by other bodies that have received the Regulation 28 report into the death of Mr Prigent, hopefully the outline of HSE’s area of responsibility, the health and safety legislation and guidance already in place has reassured you that HSE is meeting its responsibilities as Britain’s workplace health and safety regulator. Yours sincerely Acting HM Principal Inspector of Health and Safety Agriculture Sector 4
(@NFU
Mr P Nieto Your ref:
His Majesty's Senior Coroner ;
The Coroner's Court Our ref: CP0063
Town Hall Email:
Rose Hill , —_—
Chesterfield Direct line:
Derbyshire Date: 16 January 2025
S40 1LP
Dear Mr Nieto
Response to Prevention of Future Death ("PFD") report issued on 26 November 2024
| am formally responding for and on behalf of the National Farmers Union ("NFU") to the PFD report
issued by you following the conclusion, on 15 November 2024, of the Inquest touching on the death of
Jon-Paul Prigent.
The NFU understands that it was named in the above PFD report, amongst other organisations, on the
basis that the NFU is an organisation with the ability to take actions that could potentially help to prevent
similar deaths from occurring in the future.
Our understanding from the PFD report is that Mr Prigent tragically died, on 30 July 2020, as a result of a
laden trailer decoupling from its towing tractor, and that such decoupling is unlikely to have occurred if the
hitch and coupling components had been checked and maintained to a reasonable standard.
The NFU, first and foremost, offers its sincere condolences to Mr Prigent's family and loved ones.
Despite the tragic circumstances, the NFU is grateful to the Senior Coroner for including it in this matter.
In its capacity as a Trade Association representing farmers and growers in England and Wales, the NFU
welcomes any information that can assist its ongoing work to educate its members in relation to safety
matters.
The NFU takes health and safety in the agricultural sector very seriously, as shown, for example, by the
NFU’s role chairing the Farm Safety Partnership. The NFU also provides information and guidance to its
members via a number of routes, including its website, Business Guides and the British Farmer and
Grower magazine, as well as a number of electronic newsletters. Although the NFU is primarily a
membership organisation, some information on the NFU’s website is also accessible to the public,
including a number of the NFU’s health and safety related features.
The NFU has taken, and continues to take, a number of actions with regard to this specific concern
relating to trailer coupling and the wider issue of vehicle maintenance, as | will summarise below.
NEU safety articles
The NFU produces and publishes various resources, including safety articles, which are made available
to anybody via our website, not just NFU members. Generally, these public facing documents highlight
key legal principles of which individuals working in the industry should be aware.
NFU, Agriculture House, Stoneleigh Park, Stoneleigh, Warwickshire CV8 2TZ NFU SUPPORTED BY
Tel: 024 7685 8500 Fax: 024 7685 8501 Web: www.nfuonline.com @ NFU Mutual
Registered in England No. 245E
LETTER FROM NFU HQ
These resources cover various safety-related topics including the importance of completing regular
maintenance checks of vehicles and equipment (including tractors and trailers), by competent persons, in
accordance with legislation and manufacturer recommendations.
The NFU's consistent message is that "employers must check and maintain equipment regularly to
ensure that it does not deteriorate and become a risk".
These resources include express warnings that wear to tractor hooks and trailer towing eyes "can result
in trailer disconnection if not maintained and where necessary replacea".
As a direct result of being made aware of the tragic circumstances of Mr Prigent's death, the NFU has
published a new article entitled "Agricultural trailer couplings — importance of maintenance", which
provides safety information on the specific issue of coupling mechanism maintenance. This article was
published at https:/Avww.nfuonline.com/updates-and-information/agricultural-trailer-couplings/ on 6
January 2025.
Further examples of NFU safety articles can be found via the links listed below:
e —https://www.nfuonline.com/updates-and-information/essential-information-on-farm-transport-and-
machinery/#Maintenance
e —_ https:/Awww.nfuonline.com/updates-and-information/transport-and-machinery-safety-the-importance-
of-maintenance/
e — https://www.nfuonline.com/updates-and-information/stay-safe-and-stay-legal-this-harvest/
e —https:/Avww.nfuonline.com/updates-and-information/trailer-buying-quide/
To supplement our own guidance publications, where appropriate, the NFU’s articles also include links to
relevant guidance from the Health and Safety Executive including, for example, the leaflet INDG185,
‘Using tractors safely, a step-by-step guide’ as well as relevant guidance published on GOV.uk. Hard
copies of such guidance may also be made available by the NFU at other events where appropriate.
NFU checklists
The NFU makes available checklists that help users to ensure that their vehicle or machinery is correctly
and safely maintained. Examples include:
. ‘Vehicle Health Check' (https:/Avww.nfuonline.com/media/glpaoqt0/vehicle-health-check.pdf); and
. ‘General Trailed Appliance Health Check' (https://www.nfuonline.com/media/brwj30yw/general-
trailed-appliance-health-check-2. pdf),
These documents make it clear that it is the responsibility of drivers and owners to make sure that the
equipment being used is safe.
The checklists cover a number of items that should regularly be checked (and fixed by a qualified
technician where needed) in order to ensure safety. They are designed to be a prompt, with checks to be
completed in line with manufacturers’ instructions, legislation and industry guidance. The following items
are specifically included on the checklists:
trailer hook wear and lock;
towing hitches;
transport locking devices;
braking systems (including parking and breakaway systems);
draw bars;
electrical connections; and
hydraulic connections (including breakaway systems) and piping.
NFU, Agriculture House, Stoneleigh Park, Stoneleigh, Warwickshire CV8 2TZ NFU supported by
Tel: 024 7685 8500 Fax: 024 7685 8501 Web: www.nfuonline.com rE) NFU Mutual
Registered in England No. 245E
LETTER FROM NFU HQ
Educating members
The NFU regularly highlights the importance of tractor and trailer maintenance when communicating with
its members. This is often done, for example, within the pages of the NFU's monthly magazines, British
Farmer & Grower and Farming Wales. It is also done at various member events that are held throughout
the year.
Emphasis is put on the significance of conducting daily checks and the need to ensure that the relevant
vehicle, machine or appliance is safe and suitable for the tasks at hand, as per the Provision and Use of
Work Equipment Regulations 1998.
The NFU also regularly stresses the importance of equally efficient braking systems, which will reduce
wear on the hitch, with failsafe breakaway systems employed whenever hitched to the tractor. We also
address the varieties of hitch types and have published some guidance materials around the importance
of good maintenance.
The NFU on an annual basis collates and analyses official figures relating to accidents and fatalities that
are connected to agriculture. These statistics are shared with the wider membership, with relevant case
studies where possible, so as to further evidence the importance of compliance with safety legislation,
working in line with manufacturers' regulations, suitable training of the machine and communicate the
potential impact of poor maintenance.
Education, of course, never ends and the NFU's efforts to improve safety within the farming community
are, and will continue to be, ongoing.
Please do not hesitate to contact me should you have any queries.
Yours sincerely
Secretary to the NFU
NFU, Agriculture House, Stoneleigh Park, Stoneleigh, Warwickshire CV8 2TZ NFU supported by
Tel: 024 7685 8500 Fax: 024 7685 8501 Web: www.nfuonline.com @ NFU Mutual
Registered in England No. 245E
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