Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0643, written 24 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 | 24 Dec 2025 |
|---|---|
| Reference | 2025-0643 |
| Deceased | Alan Baker |
| Coroner | Johanna Thompson |
| Coroner area | Norfolk |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Driver and Vehicle Standards Agency Berkeley House Croydon Street Bristol Somerset BS5 0DA 1 CORONER I am Johanna THOMPSON, Area Coroner for the coroner area of Norfolk 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 04 September 2024, I commenced an investigation into the death of Alan Richard BAKER aged 67. The investigation concluded at the end of the inquest on 16 December 2025. The medical cause of death was: Traumatic Chest, Pelvis and Leg Injury Road Traffic Collision 1a) 1b) 1c) 1d) 2) Ischaemic Heart Disease, Systemic Hypertension, Type 2 Diabetes Mellitus The conclusion of the inquest was: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On 7th August 2024, Mr Baker was travelling on his motorcycle along Muck Lane, Rackheath when the LGV behind which he was travelling stopped to allow another vehicle to pass and carried out a reversing manoeuvre. Due to the close proximity of the motorcycle to the LGV it ran over Mr Baker causing him to sustain catastrophic injuries. He was taken to Norfolk and Norwich University Hospital, Colney Lane, Norwich, where he sadly died as a consequence of his injuries on 25th August 2024. 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) Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have concerns that (a) there is no mandatory requirement for LGVs to have reversing cameras fitted to enable drivers to see more thoroughly behind their vehicle before carrying out a reversing manoeuvre and (b) that there is no mandatory requirement for the owners of vehicles which do have such cameras to ensure they are maintained in a fully functioning state. 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 February 17, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mrs Baker’s Next of Kin Solicitor for TP Driver Norfolk Constabulary I have also sent it to Department of Transport 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: 24/12/2025 Johanna THOMPSON Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
OFFICIAL From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft 4 February 2026 Johanna Thompson Area Coroner for Norfolk County Hall, Martineau Lane, Norwich NR1 2DH Dear Ms Thompson, Thank you for your report of 24 December 2025 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Alan Baker. I am responding as the Minister for Roads and Buses. I was very saddened to learn of Mr Baker’s death and offer my sincere condolences to his 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 regulation in this case is UNECE Regulation No. 158 (UN R158) on Approval of devices for reversing motion and motor vehicles with regard to the driver’s awareness of vulnerable road users behind vehicles. UN R158 requires all passenger and goods vehicles to be fitted with a device that warns the driver when it detects vulnerable road users to the rear of the vehicle. The regulation does not mandate a camera as UNECE regulations are generally drafted to be technology neutral, to allow for innovation as technical development progresses. UN R158 sets performance requirements and mandates that two of the following warnings are provided to the driver: audible, optical, and haptic. The Government launched its Road Safety Strategy on 7 January, and this included a consultation on proposals to mandate fitment of a range of vehicle safety technologies, including those covered by UN R158. Subject to the OFFICIAL OFFICIAL outcome of the consultation, we expect that UN R158 will be mandated in the GB approval scheme for new vehicles. Goods vehicle trailers such as the one involved in this collision are not currently in scope of UN R158. During 2025, a review of UN R158 was undertaken by the UNECE working group, and although the United Kingdom supported amending the scope to include goods vehicle trailers, there was insufficient support from other countries to do so. I believe this tragic case highlights the importance of reconsidering the scope of UN R158, and I have asked my officials to raise this in the April session of the UNECE working group. The Driver and Vehicle Standards Agency (DVSA) provides advice to operators on vehicle roadworthiness and safe operation, and will look to promote opportunities for using these types of devices and ensuring they stay effective. Should these devices become mandatory in the future, DfT and DVSA will consider if they should form part of the annual roadworthiness test and other inspections. Yours sincerely, MINISTER FOR ROADS AND BUSES OFFICIAL
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