Prevention of Future Deaths reports · 2024

Jon-Paul Prigent

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 report26 Nov 2024
Reference2024-0648
DeceasedJon-Paul Prigent
CoronerPeter Nieto
Coroner areaDerby and Derbyshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published4

The report

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

Responses

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.

Response from Agricultural Engineers Association and British Agricultural and Garden Machinery Assoc (PDF)
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.
Response from Department for Transport (PDF)
• 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
Response from Hse (PDF)
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
Response from National Farmers Union (PDF)
(@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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