Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0155, written 23 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Mar 2026 |
|---|---|
| Reference | 2026-0155 |
| Deceased | Richard Hopkins |
| Coroner | Linda Lee |
| Coroner area | Coventry and Warwickshire |
| Category | Other 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.
Linda Lee Acting Area Coroner for Warwickshire Coroner Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1. THIS REPORT IS BEING SENT TO 1. Chief Executive, Health and Safety Executive (HSE) 2. Chief Executive, Driver and Vehicle Standards Agency (DVSA) 3. Chief Executive, Society of Motor Manufacturers and Traders (SMMT) 2. CORONER I am Linda Lee, Acting Area Coroner for Coventry and Warwickshire. 3. 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. 4. INVESTIGATION AND INQUEST The investigation into the death of Richard Gary Hopkins aged 39 who died on 15 February 2024, was opened on 23 February 2024 and concluded on 12 March 2026. The inquest was conducted with a jury. The conclusion reached was a short factual narrative: Accident owing to the concurrence of two main factors; a defective trailing arm and Mr Hopkins being situated under the rear axle at the time of the malfunction. The medical cause of death was: 1a Traumatic Brain Injury 5. CIRCUMSTANCES OF THE DEATH On 14 February 2024, Mr Hopkins was carrying out a visual under chassis pre delivery inspection of a newly assembled vehicle raised on four mobile column lifts. The air suspension system remained pressurised. While he was positioned beneath the rear axle, the nearside trailing arm failed suddenly due to a hidden manufacturing defect. The airbag and bracket dropped and struck him, causing fatal injuries. Metallurgical examination identified a pre-existing internal crack together with a fresh overload fracture. The residues within the crack showed that it had formed at, or before, the quenching stage of manufacture. Although the manufacturing processes and available production data were reviewed, the underlying reason for the defect could not be determined and therefore cannot presently be prevented. The defect was not detectable during a pre delivery inspection. Thousands of similar trailing arms have been produced without incident, and this appears to be the only recorded fracture of its kind. Batch sample non- destructive testing is widely relied upon for components not categorised as safety critical in operation. This incident demonstrates, however, that such testing, while providing assurance as to general production quality, cannot eliminate the possibility of a rare, isolated defect in an individual component. The remainder of the batch was tested after the incident, and no further defects were identified. Existing national guidance acknowledges that parts within pressurised air suspension systems may fail when work is being carried out on those systems, particularly where the task may disturb components. Before this incident, it was not considered possible for a component to fail in comparable fashion during a purely visual inspection when the system was undisturbed and no work was being performed on it. This incident demonstrates that such failure can occur during inspection and can expose an operative to risk solely due to proximity beneath a raised and pressurised suspension system. Following the incident, the employer introduced straightforward measures that removed exposure to this risk in the pre delivery inspection environment. These included carrying out relevant checks earlier in the production process, before the vehicle is fully assembled and before the suspension is raised and pressurised and introducing an exclusion zone beneath the rear suspension whenever a vehicle is raised. 6. MATTERS OF CONCERN a) Previously unrecognised proximity risk The investigation revealed a previously unrecognised proximity risk to inspectors working beneath raised and pressurised air suspension systems during visual pre delivery inspections. Although the defect in this case was exceptionally rare, a sudden and undetectable failure in these circumstances presents a clear risk of fatal injury. b) Absence of guidance addressing failure during undisturbed inspection Existing national guidance recognises the possibility of component failure when work is being carried out on a pressurised suspension system. It does not address the distinct risk demonstrated by this incident: that a component may also fail unexpectedly during an undisturbed visual inspection when the operative is not working on the system. c) Limitations of batch sample testing Batch sample non-destructive testing, although widely accepted for components not designated as safety critical, cannot fully guard against a rare, isolated hidden defect in an individual part. Inspectors may therefore be unknowingly positioned beneath a component capable of unexpected failure under pressure. d) Lack of awareness of this inspection phase risk across the sector The evidence demonstrated that the inspection phase proximity risk identified in this case was not appreciated by the employer or more widely within the sector. The measures introduced after the incident show that the risk can be effectively eliminated once recognised, but its existence had not been understood before this incident. 7. ACTION In my opinion, action should be taken to prevent future deaths and I believe your organisations have the power to act. 8. RESPONSE You are under a duty to respond to this report, setting out what consideration you have given to the concerns raised, namely by 18 May 2026. 9. COPIES A copy of this report is being sent to the Chief Coroner. It may be published on the judiciary website. It is also being sent to the following Interested Persons: (cid:127) The family of the deceased (cid:127) The employer (cid:127) The Health and Safety Executive Linda Lee Acting Area Coroner for Coventry and Warwickshire 23 March 2026
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.
Berkeley House Croydon Street BRISTOL BS5 0DA T (0117) 954 3211 www.gov.uk/dvsa Linda Lee Acting Area Coroner for Warwickshire Coroner Service by email: richardtoms@warwickshire.gov.uk our ref: 2603-104622 8 April 2026 Dear Ms Lee Thank you for your letter of 23 March about the inquest into the death of Richard Gary Hopkins, which was concluded on 12 March 2026, and the resulting regulation 28 report to prevent future deaths. We should like to offer our condolences to Mr Hopkins’ family and friends. I can confirm that we at Driver and Vehicle Standards Agency (DVSA) were engaged fully with the Health and Safety Executive (HSE) and attended hearings to determine whether there was anything we could or should do. We also engaged with the vehicle manufacturer in the same way we would where there is the suggestion of a potential vehicle safety defect. Following this work, it was confirmed this was an isolated incident affecting that single component, and no safety recall action was appropriate. On the broader point of safety in the workplace, this is predominantly a matter for other agencies such as the HSE. As usual, we will continue to collaborate with HSE to find opportunities to discuss mitigations that employers can implement to address this kind of problem, for example, in any trade communications or guidance. We have not identified any necessary actions given the unique nature of this particular incident. But we continue to support industry efforts (generally through trade associations) to improve safety in commercial vehicle workshops and have supported a number of areas of good practice guidance (such as on wheel chocking and vehicle loading) and will flag this as an area that could be considered. I am happy for a copy of this response to be sent to all the interested parties. Yours sincerely Chief Executive Helping you stay safe on Britain's roads
Health and Safety Executive Ms Linda Lee Acting Area Coroner for Warwickshire Coroner Service Chief Executive Redgrave Court Merseyside L20 7HS 12 May 2026 Dear Ms Lee, Thank you for your letter dated 23 March 2026 concerning the inquest into the death of Richard Gary Hopkins and the resulting Regulation 28 Report to Prevent Future Deaths. On behalf of the Health and Safety Executive (HSE), I offer my sincere condolences to Mr Hopkins’ family and friends. Your report raises as matters of concern, that: a) There was a previously unrecognised proximity risk associated with visual inspection of pressurised air suspension systems which may result in fatal injury; b) There is an absence of guidance addressing component failure during undisturbed inspection; c) There are limitations to the non-destructive batch testing of the component in question, namely the suspension trailing arm; d) There is a lack of awareness of this pre-delivery inspection phase risk across the sector. I will address each of these points in turn. Previously unrecognised proximity risk associated with visual inspection of air suspension systems It is agreed that this is a previously unrecognised risk as there is no known history of relevant similar incidents associated with component failures of this nature. We are aware of previous incidents involving the failure of air suspension components which have resulted in serious or even fatal injuries. However, the circumstances of those incidents all involved physical interaction with the air suspension system prior to failures occurring. Enquiries with the component manufacturer and the vehicle manufacturer suggest that this is also the only component failure they have experienced in such circumstances. Under health and safety law, employers are required to manage risks to their employees so far as is “reasonably practicable”. This involves carefully weighing the level of risk against the time, cost and effort required to control it. When assessing the level of risk, it is important to consider not only the potential severity of an outcome, but the likelihood of it occurring. Our investigation concluded that this instance represented a single, isolated failure involving a component that is manufactured in significant volumes each year. While the potential severity is rightly recognised as high, the available evidence indicates that the likelihood of a similar event occurring is very low. Absence of guidance addressing component failure during undisturbed inspection The possibility of component failure on air suspension systems is addressed in a number of HSE documents: HSG 261 – Health and safety in motor vehicle repair and associated industries (page 41) PM85 – Safe recovery (and repair) of buses and coaches fitted with air suspension; INDG 434 – Working safely under motor vehicles being repaired; Air suspension systems on vehicles (HSE Website); Safety Alert – EPD1 - 2020. This guidance focuses on the risks linked to repair or recovery work on vehicles with air suspension. This reflects the fact that there have been serious and fatal incidents associated with this type of work in the past. Currently, there is no specific guidance covering pre-delivery inspections carried out under vehicles. This is because, before the incident involving Mr Hopkins, evidence of component failure had been limited to situations arising during normal vehicle use. Following a recent meeting of the Motor Vehicle Repair Forum (MVRF) on the 8th of May, MVRF members agreed to review the HSE guidance documents INDG 434, HSG 261 and PM85 with specific consideration for the incident involving Mr Hopkins. The MVRF is an external stakeholder group comprising a number of trade bodies and associations who, along with HSE, are committed to reducing injuries and ill-health in the motor vehicle sales, repair and recovery sector. We play an active role in the activities of this group. Limitations of batch sample testing As the enforcing authority for the safety of components on road-going vehicles, the Driver and Vehicle Standards Agency (DVSA) undertook an investigation on the component which failed and tested samples from the same production batch. The findings of this investigation were shared with us during our own investigation, and I understand that no further concerns were raised by DVSA over the component design or the manufacturing/testing process. Lack of awareness of this inspection phase risk across the sector We have worked with stakeholder groups including the MVRF to raise awareness of the circumstances of this incident and the findings of both the Inquest and our own investigation. We will continue to explore opportunities to raise awareness of this risk in relevant industry sectors going forward. I hope this response is of use, and fully addresses the concerns you have raised that fall into the remit of the Health and Safety Executive. Yours sincerely, Chief Executive
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