Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0611, written 5 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Dec 2025 |
|---|---|
| Reference | 2025-0611 |
| Deceased | Leonardo Machado |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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 (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 Work and Pensions 2) Secretary of State for Business and Trade 3) Secretary of State for Transport 4) Secretary of State for Education 5) Chief Executive of the Health and Safety Executive 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 30th January 2026. 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 At the request of the Home Office, the initial recipient of the original report to prevent future deaths dated 23rd September 2025, the following have also been sent a copy of the report: (1) (2) (3) (4) (5) of the Department for Business and Trade of the Department of Transport of the Health and Safety Executive of the Department for Education of the Home Office 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 5th December 2025 Signed Brendan J Allen 4
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.
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,
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