Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0476, written 18 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2025 |
|---|---|
| Reference | 2025-0476 |
| Deceased | Leonardo Machado |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) Secretary of State for the Home Department 2) Uber Eats 3) Deliveroo 4) Just Eat 1 CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset 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 19th April 2023, an investigation was commenced into the death of Leonardo Cardoso Machado, born on the 13th July 2005. The investigation concluded at the end of the Inquest on the 11th September 2025. The Medical Cause of Death was: 1a Traumatic Head and Neck Injuries 1b 1c 2 The conclusion of the Inquest as recorded by the jury empanelled to hear the Inquest was that Leonardo Cardoso Machado died at Lindsay Road near junction with St Aldhelm's Rd, Poole, Dorset on 16th April 2023. 1 On balance of probability the fact the Police attempted to effect a traffic stop at the County Gates Gyratory caused Leo to "make off" at high speed through the red traffic lights to continue to travel at speed along Lindsay Rd. The excessive speed of the motorbike driven by Leo was the causative factor in the collision causing Leo to lose control at the bend in the road and drive into the railings on Lindsay Rd. The cause of death was traumatic head and neck injuries caused by the road traffic collision. 4 CIRCUMSTANCES OF THE DEATH Leo was 17 years of age at the time of his death. Leo “rented” an “Uber Eats” delivery licence, though he was too young to obtain such a licence himself. As a result of the rented licence, Leo was able to earn money as a food delivery driver. In the early hours of 16th April 2023 Leo was riding a 599cc Yamaha sports bike with an “Uber Eats” delivery box attached to the rear. He was not licenced to use such a motorcycle, which requires a full category A driving licence, with the licence holder being 21 years of age or older. Leo had been stationary on the motorcycle at a red light when approached by police. He made off at speed and subsequently lost control of the motorcycle, colliding with metal railings and sustaining injuries that caused his death. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or 2 motorcycles and delivering to individuals that are not known to the drivers. 2. I have concerns with regard to the following: i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I heard is a national issue; ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position; iii. That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, by 18th November 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 Chief Coroner and to the following Interested Persons: (1) father) (Leo’s mother) and (Leo’s ste- (2) (3) Chief Constable for Dorset Police (4) Independent Office for Police Conduct (5) Dorset Child Death Overview Panel (Leo’s father) 3 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 23rd September 2025 Signed Brendan J Allen 4
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.
Deliveroo 1 Cousin Lane London EC4R 3TE Brendan Allen Area Coroner for Dorset Town Hall Avenue Road Bournemouth Dorset BH2 6DY 19 November 2025 Dear Mr Allen Prevention of Future Deaths Report regarding the death of Leonardo Machado Thank you for your Report to Prevent Future Deaths dated 18 September 2025 regarding the death of Leonardo Machado (the “ Report ”). Firstly, we wish to offer our condolences to Leo’s family and loved ones for their loss. In the Report you raised concerns that children under the age of 18 may be renting food delivery accounts. You are concerned that this might place children in a vulnerable position where they are working alone at night and on motorised vehicles at risk of a traffic collision and potential death. Riders must be aged 18 or over to carry out deliveries for Deliveroo. We have strict controls to prevent individuals aged under 18 from onboarding and creating delivery accounts - these are detailed further below. Riders may allow others to use their account (substitution is a feature of self-employment in the UK) but account holders are not permitted to share their delivery accounts with individuals who are under 18 years old. This is clear in our Rider Supplier Agreement and on our rider website. You might be aware that over the course of this year, we have been working closely with the Home Office and other food delivery platforms to enhance compliance with right to work legislation by food delivery couriers. We have significantly strengthened checks and processes that we already had in place to ensure that rider accounts are only being used by Deliveroo Roofoods Limited, 1 Cousin Lane, London, EC4R 3TE authorised individuals. Although your concerns do not relate to right to work specifically, the work being carried out in this area strengthens our processes to prevent riders operating on our platform without our authority or knowledge. This includes individuals who are under 18 years old, who are prohibited from accessing our platform under the terms of the app. In preparing our response, we have reflected on our internal procedures, including changes made to the way we operate following engagement with the Home Office. As summarised below, we are confident we have a robust framework designed to reduce the risk of unauthorised riders accessing our platform and we trust you find the response helpful. Measures to prevent unauthorised platform access Deliveroo takes this matter very seriously and has a framework of safeguards in place to reduce the risks of unauthorised access to our platform, including by those who are under 18. In particular: 1. 2. 3. 4. 5. 6. 7. It is a requirement that any rider engaged with Deliveroo is at least 18 years old. As part of our onboarding process, we take steps to establish the identity of our riders to ensure we know who we are engaging and verify their right to work. As part of that process, all riders are required to provide an official document that evidences their date of birth. This might be a passport, driving licence or birth certificate for example. These documents are checked before the rider is granted a delivery account. A delivery account will not be granted to an individual unless their documents show they are over 18 years old. Once a rider has access to a delivery account, as is the case for all self-employed individuals in the UK, they are allowed to substitute their services to other people. However, we require all substitute riders to be registered with us before they can provide services on behalf of the main account holder. As part of this, all registered substitutes must complete the same process to establish their identity and their right to work, meaning that they provide evidence of their date of birth in the same manner as the main account holder. Substitution is explained in more detail below. We run facial recognition checks to ensure that the person using an account is either the main account holder or a registered substitute and to detect and prevent unauthorised use of the platform. These checks are run at least daily for all riders in the UK. This process requires the rider to submit a live video selfie, which is then checked by our third party supplier to make sure it matches the ID they provided during onboarding. If riders do not pass, their accounts are placed out of service, meaning that they cannot accept orders until they have passed a check. Facial recognition checks are triggered in various different scenarios. The checks are designed to detect unauthorised riders in the areas of most common abuse on our rider app. We have recently increased the frequency and sophistication of these checks, including randomising the frequency of intra-day checks to make it harder for people to predict the checks. Our facial recognition technology identifies any failed checks that indicate someone other than the main account holder, or registered substitute, may have been trying 2 8. to conduct a facial recognition check on their behalf, or where there is other evidence of fraud. These are reviewed by our teams and where we find evidence of unauthorised account sharing, we terminate the supplier agreement with the riders. We also have other measures in place to enable us to identify suspicious activity or if an unregistered substitute is attempting to use our platform. Where we identify breaches of our processes, we take appropriate action, including terminating supplier agreements with riders where necessary. We stop working with riders who allow an unregistered substitute to use their rider account and will not work with those riders in the future. We have processes in place to enable us to identify whether a rider applicant has previously had a supplier agreement with us terminated for allowing an unregistered substitute to provide services on their behalf. Substitution of to the food refer renting delivery licences. You Deliveroo engages riders on a self-employed basis; we do not operate food delivery licences. We understand that when using this term you may be referring to substitution - where one rider completes a delivery on another rider’s behalf. Substitution has always been, and continues to be, a common feature of self-employment. It is not specific to Deliveroo, nor our sector. Individuals with a Deliveroo rider account are able to arrange for a substitute to provide the delivery services on their behalf. As mentioned above, substitutes must also be registered and pass the same identity checks as a main account holder to provide services to Deliveroo. Self-employment and substitution provides riders with the flexibility to choose when, where, how and if they want to provide their services to us. This is a valuable way of working for self-employed individuals, including riders. We continue to monitor interaction with our app to further enhance our security checks and features to prevent abuse, so our platform remains safe and secure for the riders who work with us and our wider communities. We trust that this helps to allay any concerns you may have had. Yours sincerely Deliveroo VP European Operations For and on behalf of Roofoods Ltd (t/a Deliveroo) 3
Health and Safety Executive Deputy Director for Technical Support and Engagement Health and Safety Executive Engagement and Policy Division Mr Brendan J Allen Area Coroner for the County of Dorset 30 January 2026 Dear Mr Allen Regulation 28 - Prevention of Future Deaths ( ) Thank you for your letter and Prevention of Future Deaths report of 5th December 2025, , and arising from the inquest into the addressed to HSE’s Chief Executive, unfortunate death of Mr Machado whilst using a ‘rented’ Uber Eats licence. has asked me to respond to you in my capacity as HSE’s Deputy Director for Technical Support and Engagement This was essentially a road traffic accident, and you acknowledge that excessive speed was the causative factor in Mr Machado losing control of the motorcycle he was riding. However, you also raise concerns around the rental or sharing of permits for these platforms, the employment of minors and lone working. In leading the response, the Health and Safety Executive (HSE) has sought the views of several other governmental organisations, and these are included in our response below which viewed together describe a comprehensive framework of guidance and legislation. However, that does not mean that we are complacent, and you will also note proposals to improve on the current situation. Riding and driving for work: In respect of the road traffic accident itself, HSE views that road traffic accidents are generally a matter for the Police to investigate and enforce, rather than HSE, using the most applicable legislation. This is set out in Health and Safety at Work etc Act 1974 - Section 3. The Department for Transport (DfT) commented that the safety of anyone driving or riding on our roads is a priority, and that includes those who drive for work. The government expects that employers or engagers of anyone driving or riding for work to ensure that they are as safe as possible on our roads. DfT worked closely with the HSE to update the joint DfT/HSE guidance on work related road safety. The revised guidance, published in September 2021 and called Driving and riding safely for work, clearly sets out what commercial organisations and their workers, whether employees or self-employed, must do to manage work-related road safety by reference to their obligations under law. DfT has also announced as part of the Road Safety Strategy that it will pilot a National Work-Related Road Safety Charter for businesses that require people to drive or ride for them. The aim of the Charter is to help employers to reduce work-related road risk and improve safety for all road users by promoting good practice, and to improve compliance with current legislation and guidance. It will include the use of Heavy Goods Vehicles (HGV)s, Light Goods Vehicles (LGVs), cars, motorcycles, e-cycles and cycles. The pilot will run for two years and will be monitored and fully evaluated. The tragic death of Leonardo Cardoso Machado has raised several important concerns. DfT is committed to making our roads safer and we are ready to work with others to achieve this. Road safety is a shared responsibility, and DfT’s strategy reflects that. It considers action needed by government, local authorities, industry, emergency services and communities to tackle the causes of collisions and save lives. By investing in infrastructure, education, and enforcement, DfT are taking decisive steps to make our roads safer for everyone. Sharing of permits The sharing of permits between licence owners and “substitutes” is a contractual issue and not an area HSE has any control over. The Department for Business and Trade (DBT) are the more appropriate governmental body, and they have addressed the practice of “renting” food delivery licences to under 18’s and the concerns that this raises. Food delivery companies do often allow account holders to use other people to carry out work for them under their account. This practice is sometimes referred to as substitution or sending a substitute. The ability for someone who is self-employed to subcontract work is a key feature of self-employment and is a lawful commercial arrangement. It is not something that is regulated or licensed by government in food delivery, or many other sectors where this practice can be found. As the report notes, most food delivery firms require that all riders and their substitutes are at least 18 years old. The government has been working closely with food delivery firms so that they increase the use of facial verification checks and fraud detection technology to ensure only registered account holders and their registered substitutes can work off their platforms. Employment of Minors: HSE has some high-level guidance on the employment of young people under the age of 18: Young people at work: Overview - HSE. The Department for Education state that the restrictions on child employment in the Children and Young Person’s Act 1933 apply to children who are of compulsory school age. Therefore, these restrictions would not apply in the case of Leonardo Cardoso Machado who, as a 17-year-old, would be classed as a ‘young worker’. However, we note from the response from Uber Eats UK Limited to the coroner on 18 November 2025, that their terms and conditions include requirements that persons under the age of 18 are prohibited from having a delivery licence or to act as a substitute. Lone Working: It is well known and established that lone working can present a risk to workers, and this should form part of an employer’s risk assessment. This includes the requirement to assess risks and should consider ways in which the work can be organised to minimise the potential for harm. Relevant training, supervision, monitoring and support should be provided for lone workers. HSE specifically considers lone workers in providing guidance and this covers both the employers of lone workers and the lone workers themselves; Lone working - HSE. However, HSE acknowledges that there are practical limits to what can be done in the driver delivery sector because work like this inevitably involves working alone, to deadlines, often at night and with the attendant road risks. Lastly, a great deal of work is going on between government and the food delivery industry to tighten control and reduce abuse of legitimate systems such as substitution, for example this initiative Delivery firms to bolster rider security checks to stop illegal working - GOV.UK. The new Employment Rights Act 2025 is also aimed to address weakness of current system - Employment Rights Act 2025: overview factsheet I trust that this response from HSE, along with the contributions from the other governmental departments, gives you confidence and reassurance that the issues raised in his report are actively being addressed. Yours sincerely,
RE Report to Prevent Future Deaths 25 November 2025 Dear Mr Allen, Thank you for sending us a copy of your report. I was saddened to read about the death of Mr Machado in your report and I extend my deepest sympathy to his family and loved ones. I am writing in response to your request for further information on the actions we take around courier safety. For some background context, Just Eat is predominantly a marketplace, which means that the majority of the partners on our platform are independent businesses who directly employ or engage their own couriers. To complement this, we offer delivery for restaurants that do not have this service, engaging with self-employed independent contractors. We have high standards for those that deliver on behalf of the business and our expectations are clearly communicated to couriers as part of onboarding and guidance processes, with a clear courier agreement which couriers sign up to in order to deliver on our network. When couriers sign up to the Just Eat network, we conduct background checks to determine eligibility, including checks that the courier is over the age of 18, has the right to work in the UK, does not have criminal convictions, and, if applicable, holds a suitable driving licence. Under the UKʼs employment law, self-employed independent couriers have the legal, unfettered right to use a substitute and Just Eat provides guidance to couriers on how they can do this safely and responsibly. Whilst couriers have the legal right to substitute their work, this can only be to others who are over the age of 18 and have the legal right to work in the UK. We have recently introduced further enhanced checks to ensure that substitutes meet the requirements that we set for all couriers on our network. Couriers must now pre-register any substitutes and are given a short grace period to complete biometric checks and to submit documents proving their age and that they have the right to work. If these documents are not provided, both the main account holder and their substitutes will be removed from the network. Couriers also undergo random biometric screening checks throughout their runs to ensure the people using the accounts are only those who have been verified to do so. More broadly, courier safety is a major focus at Just Eat and we have escalation processes in place for any serious issues raised. We are in regular contact with our couriers with a chat function within the app which couriers can use to raise any concerns and we have a safety and support section within our courier help centre which provides couriers with information on reporting incidents. We closely monitor any incidents regarding courier safety so that we can support our 1 courier network effectively. We also provide extensive safety guidance materials available on our courier website. I hope this letter has provided you with assurances on our processes and we would be happy to discuss this further if you require. Kind regards, Senior Delivery Director UK&I 2
Uber Eats UK Limited Floors 13-15 Aldgate Tower 2 Leman Street London 18 November 2025 Dear Area Coroner, Thank you for your letter dated 6 October 2025 and the enclosed Prevention of Future Deaths report dated 23 September 2025 touching upon the death of Mr. Machado. Everyone at Uber Eats was deeply saddened to hear of this incident. We would like to express our sincere condolences to Mr Machado’s family and friends. It has been reported that Mr. Machado may have been travelling with an Uber Eats branded bag on the back of the motorcycle on the night of the incident. We have carried out a thorough investigation and can confirm that Mr Machado was not carrying out deliveries arranged through the Uber Eats platform, as a substitute courier or otherwise, on the night of the incident on 16 April 2023. Coroner’s concerns This note sets out Uber Eats’ response to section 5 of the PFD Report and, in particular, the Coroner’s matters of concern which are as follows: 1. During the inquest evidence was heard that: i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers. 2. I have concerns with regard to the following: i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I heard is a national issue; ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position; iii. That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death. Uber Eats’ response We would like to begin by stating unequivocally that everyone delivering on the Uber Eats platform must be at least 18 years of age. This requirement is set out clearly in our Courier Terms and Conditions that all couriers sign in order to use the app and we have a number of robust checks in place (outlined below) to ensure this requirement is met. If we become aware of someone delivering on the platform who may be under 18 we take immediate action, including reporting to law enforcement or relevant authorities where necessary. The safety of couriers, customers and community is of the utmost importance to Uber Eats. To register for an Uber Eats account, all couriers must pass a) identity document verification conducted by our own specially trained teams and b) comprehensive fraud checks conducted by an expert third party (including Ubble, First Advantage). An account will only be approved if a courier’s identity document and date of birth is verified at each stage. As independent contractors, couriers have the right to subcontract (or ‘substitute’) to a person of their choosing so long as their substitute meets certain safety criteria, including being at least 18 years of age. This requirement is made explicit in the Courier Terms and Conditions. The age of registered substitutes is verified using the same process as above: multiple, comprehensive verification checks conducted by our internal team and independent expert providers to confirm their date of birth. To help ensure that only the account holder or registered substitutes (i.e. those confirmed to be over 18) are using the account, Uber Eats uses industry leading account-sharing detection technology. This includes real-time identity verification software (launched in 2019), which requires couriers to take a selfie that is compared in real time with the profile photo that has been matched with their registered identity documentation. These real-time facial verification checks occur randomly, at least once a day and also in circumstances where we suspect that an individual performing the delivery may not be the same person as the accountholder. In addition to these checks, we monitor for suspicious behaviours that may indicate attempts to circumvent our security controls, which can trigger additional identity verification checks. If we were to become aware that a courier was attempting to share their account with a minor - whether as a substitute or by providing unauthorised access to their own account - we would take immediate action, including suspending the account to investigate and taking any appropriate steps, which may include contacting relevant authorities. We have a dedicated 24/7 Public Safety Team, who respond to law enforcement data requests and regularly engage with law enforcement to support a swift and effective response to incidents. We are continually enhancing our processes to ensure our platform is safe. Although action taken was not in direct response to this incident, we have refined and added to our suite of account-sharing detection signals in recent years. We hope this response assists the coroner’s consideration of the matter, and we would like to once again express our deepest sympathies to Mr. Machado’s family and friends for their loss. Yours faithfully Uber Eats UK Limited Uber Eats UK Limited
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