Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0592, written 20 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Nov 2025 |
|---|---|
| Reference | 2025-0592 |
| Deceased | Lisa Bowen |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Re : Lisa Marie Bowen, Deceased
Regulation 28 Report to Prevent Future Deaths
Regulation 28 Report to Prevent Future Deaths
This Report is being sent to:
1. Toyota (GB) PLC, Toyota Motor Corporation, and Toyota Motor
Europe NV/SA in relation to Concern 1,
2. The Secretary of State for Business and Trade in relation to Concern
1,
3. The Secretary of State for the Department of Transport in relation to
Concerns 1 and 2, and
4. Driver and Vehicle Standards Agency in relation to Concerns 1 and
2.
1 CORONER
I am Richard Travers, HM Senior Coroner for Surrey.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7 of Schedule 5 to the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.
3
INVESTIGATION and INQUEST
I commenced an investigation into the death of Lisa Marie Bowen. The
inquest concluded on the 1st August 2025 when I found that the medical
cause of death was:
Ia Traumatic Head and Spinal Injuries
and my conclusion as to the death was:
Road Traffic Collision
I subsequently held a hearing, on the 6th November 2025, to receive
evidence relating to the prevention of future deaths.
4 CIRCUMSTANCES OF THE DEATH
On the morning of the 11th January 2022, Lisa Bowen was driving her
Toyota Corolla motor car on the M25 motorway when its rear offside tyre
deflated. A tyre deflation warning light probably appeared on the
dashboard, but it was not possible to ascertain whether Ms Bowen saw it
and, if she did, whether or how she responded. She drove on for at least
several miles, as a result of which the tyre was damaged and its tread and
parts of its sidewalls detached.
Following the tyre detachment, Ms Bowen braked, indicated, and moved
on to the hard shoulder. Once on the hard shoulder, she pressed the brake
pedal a further five times, with increasing force, but this did not result in
any significant reduction in the Toyota’s speed. In consequence, the
vehicle did not stop prior to colliding into, and under-running, the rear of
a lorry which was present and stationary on the hard shoulder. The
Toyota’s speed at the time of the collision was 37.9 miles per hour. The
collision occurred 17 seconds after the tyre detachment and ten seconds
after the Toyota moved on to the hard shoulder. The collision caused
catastrophic damage to the Toyota and, as a result, Ms Bowen suffered
fatal injuries and died instantaneously.
If the brakes had worked effectively, there would have been time and
distance for the Toyota to have stopped before the collision. The brakes
did not work effectively because, when the brake pedal was pressed, the
vehicle’s anti-locking braking system was activated, and it operated to
reduce the braking effect almost entirely.
The anti-locking braking system was working in accordance with its
design.
The outcome was an unintended effect of the system’s design which arose
because the specific scenario, of tyre detachment occurring whilst the
vehicle was being driven, which was thought to be a rare occurrence, had
not been taken into account in the design process.
My full findings are set out in the Findings and Conclusion document
which is sent with this report.
5 CORONER’S CONCERNS
In my opinion the following concerns arise and gives rise to a continuing
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 :
Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not
work effectively because, when the brake pedal was pressed, the vehicle’s
anti-locking braking system was activated, and it operated to reduce the
braking effect almost entirely. At the inquest I heard evidence that:
(i)
Following the tyre detachment, the speed of the wheel with a
detached tyre was much higher than the speed of the three other
wheels with undamaged tyres.
(ii)
The anti-locking braking system recognised this differential in
speed, but perceived that the problem lay with the three slower
wheels and assumed that they had locked or were at risk of
doing so.
(iii) Consequently, each time the brake was applied, the anti-locking
braking system immediately released the braking pressure to
the three slower wheels in order to avoid them locking, thereby
prioritising the preservation stability and steerability over
braking.
(iv)
In this way, the anti-locking braking system was working in
accordance with its design.
(v)
The system was unable to recognise that the problem in fact lay
with the fourth wheel which was rotating much more quickly
than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design
which arose because the specific scenario, of tyre detachment
occurring whilst the vehicle was being driven, which was
thought to be a rare occurrence, had not been taken into account
in the design process.
(vii) Testing of anti-locking braking systems and braking
performance, following a tyre detachment, is not undertaken by
the industry as a whole and, therefore, relevant data is not
collated.
At the inquest and PFD hearing I was informed that –
(i)
A large number Toyota Corolla motor cars continue to be driven
on the roads of the UK with the same anti-locking braking
system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number
of specialist companies and it may well be that other vehicles
currently on the roads of the UK have systems similar to that in
Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system
used in Ms Bowen’s car (Advics) has since developed and
improved its system so that it is better able to recognise if one
wheel speed is so different from the others that the data from
that wheel should be ignored as unreliable. However, the
improvements are not foolproof, not least because acceleration
or deceleration of the vehicle affects this function.
(iv)
The anti-locking braking system now used in Toyota Corolla
motor cars has been developed by a different company (Bosch)
and it is not known by Toyota precisely how it would respond
following a tyre detachment whilst the vehicle is being driven.
(v)
It seems that relevant regulations concerning anti-locking
braking systems do not address or specify requirements relating
to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is
thought to be a rare occurrence, I am concerned that that may not be the
case and that if it were to happen again, in the same or similar
circumstances, the risk of future death continues.
Concern 2
This concern relates to the catastrophic failure of the under-run protection
bar (‘the Device’) that was in place on the lorry with which Ms Bowen
collided. At the inquest I heard and accepted expert evidence which
established that:
(i)
The Device was compliant with all relevant regulations and
legal requirements, save only that fixing bolts of an incorrect
strength had been used to attach it to the lorry’s chassis.
(ii)
The strength of the Device was grossly insufficient, either to
have prevented any underrun, or even to have reduced the
extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if
the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection
devices are capable of providing protection against much greater forces
than is currently required under the law and he expressed disappointment
that the relevant legislation and regulations are not more robustly framed,
so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in
relation to the degree of force that an under-run protection device should
be capable of withstanding, a risk of future death arises.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths by
addressing the concerns set out above and I believe your organisation has
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 the 16th January 2026. I, as 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:
Scania GB Limited,
The Family of Lisa Bowen,
(i)
(ii)
(iii) West Pennine Trucks Limited, and
(iv) PPS Commercials Limited
I am also under a duty to send a copy of your response to the Chief
Coroner.
I may also send a copy of your response to any other 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
20th November 2025 Richard Travers
2 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.
OFFICIAL-SENSITIVE From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR 15 January 2026 Mr R Travers HM Coroner HM Coroner’s Court Station Approach Woking GU22 7AP Dear Mr Travers, Thank you for your report of 20 November 2025 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Lisa Marie Bowen. I am responding as the Minister for Roads and Buses. I was saddened to hear of Ms Bowen’s death and offer my sincere condolences to her family and friends. The Department is strongly committed to improving the safety of all road users, and this includes ensuring that new vehicles are approved, to demonstrate that they comply with a range of technical requirements before they can be sold. The United Nations Economic Commission for Europe (UNECE) is the principal body for vehicle regulations, and the UK is an active member of its technical committees. The relevant regulations in this case are United Nations Economic Commission for Europe (UNECE) Regulation No. 13H on the Approval of Passenger Cars with Regard to Braking (“R13H”) and Regulation No. 58 on the Approval of Rear Underrun Protective Devices (RUPD) (“R58”). Having reviewed your report, and considered the current provisions in UNECE Regulations, I have instructed my officials to examine the possibility of introducing further amendments to these regulations to address the concerns raised. The Vehicle Certification Agency (VCA) confirmed that the braking system of the car involved in the collision was approved to R13H. Recent amendments have been made to the provisions of R13H to allow approval authorities more scrutiny over the functioning of brake systems in non-fault conditions, but these are applied at the discretion of the issuing authority. OFFICIAL-SENSITIVE OFFICIAL-SENSITIVE My officials will therefore highlight the particulars of this case at the relevant UNECE forum in May and collaborate with members of that forum on whether specific provisions are necessary for R13H. VCA also confirmed that the RUPD fitted to the heavy goods vehicle was approved to the 02 series of R58. Since 1 September 2021, all new registered trailers under GB whole vehicle type approval must meet the 03 series. Amendments included an increase the test forces by up to 100%; lowered the ground clearance requirements; and increased section height of the cross-member. These changes were introduced to help reduce the severity of future rear collisions like this one. The above measures will only resolve the risk in new vehicles. Since there is considerable uncertainty over the potential risk to existing vehicles on the road, I have asked my officials to gather what relevant information they can over the coming months to better understand the situation. From this my department will consider whether any retrospective action should be taken. Yours sincerely, MINISTER FOR ROADS AND BUSES OFFICIAL-SENSITIVE
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
By email & post
Dear Mr Travers,
16 January 2026
This letter is written on behalf of the three Toyota companies: Toyota (GB) PLC (“TGB”), Toyota Motor
Europe NV/SA and Toyota Motor Corporation, (collectively referred to as “Toyota”) in response to the
Regulation 28 report to Prevent Future Deaths ("PFD report") you issued on November 20, 2025.
At the outset, we would like once again to express our sincere condolences to Ms. Bowen’s family and
friends for their dreadful loss. We are grateful for the care that you took in the course of your investigation
and, in particular, in the detailed consideration of the evidence at the inquest hearing.
In addition to our involvement in your investigation, Toyota has cooperated fully with the police and has
engaged with its relevant regulator in the UK, the DVSA.
Neither the police nor your investigation concluded that there was any fault with Ms. Bowen’s Corolla.
On the contrary, you found that the car’s Anti-Lock Braking System (“ABS”) worked in accordance with
its type-approved design.
You are, however, concerned at the way in which the ABS operated in the particular circumstances of
this accident – namely when the tyre tread and sidewall completely detached from the wheel while
driving. Your concern extends industry wide as you noted that vehicles manufactured by other
companies may have systems of a similar design to that in Ms Bowen’s car and the relevant regulations
concerning such ABS do not address or specify requirements relating to the scenario faced by Ms
Bowen.
Safety of Toyota vehicles
Please may we start by assuring you that all Toyota vehicles sold in Europe obtain Type Approval after
meeting all EU safety standards, environmental standards, and production conformity standards. These
standards also include requirements related to braking systems and ABS. ABS is a safety critical system.
It is so important that it is mandatory on all passenger cars. Great care has to be taken when considering
any changes to its design or operation. Designers have to exercise caution not to compromise
unwittingly the stability and steerability of a car.
Toyota vehicles are developed through repeated evaluations, including (and not limited to) those
required by regulations, to meet these standards. It is well-recognised that they demonstrate excellent
safety performance under reasonably foreseeable conditions. Indeed, Ms. Bowen’s Corolla received the
•• PROTECTED 関係者外秘 highest rating of 5 stars in the Euro NCAP safety assessment in May 2019. Therefore, customers can
use Toyota vehicles with confidence.
Unusual circumstances and technology limitations
No matter how excellent a vehicle’s safety features, it is unfortunately impossible to prevent all accidents.
In the real world the causes of accidents vary widely. It is not possible to anticipate every possible
situation which could give rise to an accident.
The total detachment of a tyre from a wheel of a passenger vehicle is highly unusual. You heard
evidence from an expert automotive engineering consultant who described the specific scenario that
preceded this collision – namely total tyre detachment - as “very unusual and rare”. This is consistent
with Toyota’s experience
Toyota has sold millions of cars worldwide with ABS. In only one case – this one – was the performance
of the ABS known to have been affected by a total tyre detachment. And in only one case – this one –
did such an occurrence combine with other surrounding circumstances to lead to a fatal outcome.
As in all areas of car design changes, Toyota is committed to the continued evolution of ABS. The design
is therefore regularly reviewed and, if appropriate, updated in conjunction with specialist suppliers, with
changes gradually introduced starting from new models. Although total tyre detachment (as in this
incident) is very rare, some of the ABS design changes already implemented can help detect tyre
detachment while driving.
The experts at the inquest agreed that, unfortunately, the technology does not yet exist to detect
accurately when a tyre has completely detached from a car. According to one of those experts, work is
being done to understand how anti-lock braking systems could be designed to detect complete tyre
detachment – but no one in the industry yet has the answer.
Customer awareness about tyre pressure
The evidence at the inquest showed that tyre detachment can occur when a car is driven for a distance
(at least several miles) with significantly reduced air pressure following damage to the tyre. Simply
having low tyre pressure does not cause a significant decrease in braking performance like that seen in
this accident. It is important that customers (i) are informed of the dangers of driving with low tyre
pressure and (ii) can promptly notice when their tyre pressure has dropped.
In addition to the information included in the owner’s manual/user guide, TGB regularly communicates
through its social media, customer communications and website channels to promote safe driving,
awareness of vehicle warning indicators and essential safety-check procedures. This has included
articles on the importance of tyre maintenance, tread depth, labelling, tyre pressure warning lights and
more.
TGB also continually reviews and enhances the guidance provided to customers, and training materials
provided to its retailer network, to support safe and responsible vehicle use. For example, its review
and enhancement of its Service Advisor training materials have increased awareness of key customer
vehicle safety considerations (including but not limited to the importance of wheel & tyre checks).
In addition, Toyota has been gradually implementing changes in the design of its new cars that will
ensure that drivers are provided with more information about any reduction in tyre air pressure and are
•• PROTECTED 関係者外秘 discouraged from driving when tyres are in a dangerous condition. These changes include the following
functions of the TPMS (Tyre Pressure Monitoring System):
•
•
Displaying messages according to the degree of tyre pressure loss. For example, when
the pressure drops suddenly, a message prompting the driver to stop is shown;
Including buzzer alerts according to the degree of the tyre pressure loss.
Toyota will continue its efforts to increase the awareness of our customers on tyre safety. We will
continue to work with the regulators and legislators – in particular if they decide to address or specify
further requirements for domestic vehicles in the type approval system.
The above constitutes Toyota’s response to the PFD report.
Yours sincerely,
For and on behalf of Toyota (GB) PLC, Toyota Motor Europe NV/SA & Toyota Motor Corporation
Name:
Position: Director, Customer Services
Toyota (GB) PLC
•• PROTECTED 関係者外秘
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