Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0483, written 26 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 | 26 Sep 2025 |
|---|---|
| Reference | 2025-0483 |
| Deceased | Richard Ellis |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Department for Transport, Great Minster House 33 Horseferry Road London SW1P 4DR 1 CORONER I am Joanne ANDREWS, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 I opened an investigation on 31 October 2023 into the death of Richard Ellis which concluded by the inquest. The findings in relation to section 5 of the Coroners and Justice Act 2009 were: Richard Ellis died on 23 October 2023 at Harwoods Green Lane, Stopham, West Sussex from injuries he sustained when a tractor struck him. The tractor was being used to tow the deceased’s stranded vehicle up an incline. Having freed the deceased’s vehicle, whilst still on the incline facing downhill, the tractor stopped towing and was held on its handbrake. At that time the tractor’s handbrake failed allowing the tractor to roll forwards into the deceased who was removing the tow strap attaching his vehicle to the tractor. 4 CIRCUMSTANCES OF THE DEATH The deceased was contracted to collect an electricity generator from a property which was accessed via a track on a country Estate (“Estate”). The deceased was using an Isuzu pick up (“Isuzu”) and trailer to do so. He collected the generator from the property but due to the narrow nature of the track, he was unable to turn his vehicle around to drive out forwards. Therefore, he reversed down the track with the trailer. During this manoeuvre he became stuck on an incline facing upwards as the wheels of the Isuzu and trailer had become stuck in a ditch which ran alongside the track. Regulation 28 – After Inquest Template Updated 15/07/2025 TG The deceased therefore sought assistance from local Estate workers as he needed to be towed out. The Estate workers went to the location where the deceased had become stuck with a 1996 Valmet 8130 tractor (“Tractor”) which was owned by the landowner. The Estate workers placed the Tractor facing downhill pointing towards the front of the deceased's Isuzu which was facing up the incline. The trailer was detached at that time. A strap was attached between the front of the Isuzu and the front of the Tractor. The Tractor reversed and pulled the Isuzu from the ditch. The Isuzu became free whilst still on the incline. The deceased and Tractor driver both got out of their vehicles and detached the towing strap. The Tractor driver had placed the handbrake on the Tractor prior to leaving the cab. The Tractor handbrake then failed and allowed the Tractor to roll down the incline onto its driver and the deceased. The deceased sadly died at the scene from his injuries. The handbrake was examined after the incident which demonstrated that the pawl of the handbrake was significantly worn and would likely have slipped previously. The evidence of the Tractor driver was that he had no concerns about the operation of the handbrake prior to this event. The Tractor had last been serviced in 2021 but the evidence that I heard was that it was not a legal requirement for there to be any prescribed maintenance or servicing of tractors solely used for agricultural, horticultural or forestry. 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: (brief summary of matters of concern) The evidence was that there are no legal requirements for the servicing and maintenance of agricultural tractors which do not fall within the requirements of the Road Traffic Act 1988 and the associated regulations. As such, the maintenance of these vehicles is dependent on the discretion of the vehicle owners. 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. Regulation 28 – After Inquest Template Updated 15/07/2025 TG 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 22, 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 The family of Mr Ellis The driver of the Tractor at the time of the collision The owner of the Tractor Southern Electric Power Distribution Plc Plateline Limited 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. They may send a copy of this report to any person who they believe 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: 26/09/2025 Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/07/2025 TG
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft Joanne Andrews Area Coroner for the coroner area of West Sussex, Brighton and Hove, Chart Way, Horsham, West Sussex, RH12 1XH 31 October 2025 Dear Ms Andrews, Thank you for your letter of 26 September 2025 enclosing a Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Mr Richard Ellis. I am deeply saddened to hear of Mr Ellis’s death and offer my sincere condolences to his family and friends. The Government treats road safety seriously and is committed to reducing the numbers of those killed and injured on our roads. The Road Safety Strategy is under development and will include a broad range of policies. More details will be set out in due course. While this incident has been classified as a road traffic collision, we understood it took place on a public bridlepath on a private estate. Given that, as I understand, my officials are not in possession of all the facts of the case, I have sought to provide you with a comprehensive response about the existing regulatory frameworks that might apply, hoping that relevant authorities can take this forward. Relevant agricultural vehicle regulations for public roads Once a tractor enters service on a public road, its continued roadworthiness is governed by a legal requirement that all vehicles used on the road are maintained in a roadworthy condition at all times as set out in the Road Traffic Act 1988 and the Road Vehicles (Construction and Use) Regulations 1986. These regulations cover aspects such as braking systems, steering, tyres, visibility, and overall vehicle condition, helping to ensure that agricultural tractors remain safe and compliant throughout their operational life. in 2016 on My Department conducted a consultation 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 roadworthiness testing under the Goods Vehicles (Plating and Testing) Regulations 1988. 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. 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 may lead to criminal prosecution. The DVSA publishes guidance on maintaining roadworthiness and this is available at the links provided below: https://www.gov.uk/government/publications/guide-to-maintaining- roadworthiness/guide-to-maintaining-roadworthiness-commercial-goods-and- passenger-carrying-vehicles This guidance covers what drivers and operators are legally required to do according to the law and highlights the fact that it is an offence to use an unroadworthy vehicle on the road. This guidance also gives best practice advice on the responsibilities that an operator or driver will have to consider to ensure the roadworthiness of their vehicle. This can also be used to support the maintenance of tractors solely used on private property. In addition, DVSA 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/ categorisation-of-vehicle-defects.pdf Relevant agricultural vehicle regulations for private land If tractors are operated solely on private land with no public access, they are not in scope of road vehicle regulations that apply on public roads. This includes roadworthiness regulations under the C&U regulations that create the legal requirement to ensure the roadworthiness of vehicles on public roads, although as noted above the good practice guidance published by DVSA is still relevant. If the incident took place on a private land, there is health and safety legislation (Health and Safety at Work Act 1974) that covers the maintenance and servicing of agricultural vehicles. This legislation is enforced by the Health & Safety Executive and an employer is required to ensure, so far is reasonably practicable, the health, safety and welfare of both their employees and non- employees who may be affected by their undertaking. The Provision and Use of Work Equipment Regulations 1998 (“PUWER”) provide a set of more specific duties in relation to work equipment, including that employers ensure their work equipment is maintained in an efficient state, in efficient working order and in good repair. This is also maintained by the HSE and we suggest that you consider writing to them should the circumstances of this case fall under this legislation. The HSE provides guidance for safe workplace transport in the agricultural sector which can be found at the link below: https://www.hse.gov.uk/agriculture/topics/machinery/farm-vehicles-1.htm Departmental response In total, there were 353,269 tractors licensed on roads in Great Britain (“GB”) in 2024. 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. Data on road injury collisions held by the Department shows that in the ten years from 2015 to 2024 there averaged 21 deaths per year on public roads in GB involving agricultural vehicles. The Department does not collect data on accidents that take place on private property. In view of your report, I have asked my officials to investigate how best to raise awareness of the DVSA’s published guidance on maintaining roadworthiness and to consider whether additional specific guidance on agricultural vehicle maintenance should be published. My officials will consider how best this information can be communicated to operators of agricultural vehicles, including those who operate tractors solely on private land. 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 friends and family of Mr Ellis. Yours sincerely, MINISTER FOR LOCAL TRANSPORT
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