Fatima Abukar

PFD Report All Responded Ref: 2022-0400
Date of Report 14 December 2022
Coroner Graeme Irvine
Coroner Area East London
Response Deadline est. 8 February 2023
All 10 responses received · Deadline: 8 Feb 2023
Sent To
Response Status
Responses 10 of 4
56-Day Deadline 8 Feb 2023
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns
1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London's streets, riding them on public roads is unlawful. Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021 , only 1100 were confiscated in 2022. The reduction is attributable to a change in pol icy introduced in November 2021. An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021 .
2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection .
3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
Responses
Amazon UK
14 Dec 2022
Response received
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Dear Mr Irvine, Re: The Inquest Touching the Death of Fatima Abukar A Regulation 28 Report – Action to Prevent Future Deaths

In response to your report dated 14 December 2022 (the “Report”), please find below our written response in accordance with paragraph 7(2) of Schedule 5 to The Coroners and Justice Act 2009. Thank you for sharing with us your Report and for bringing to our attention your findings and concerns. We are greatly saddened to hear about the death of Fatima Abukar and we extend our deepest condolences to her family. At Amazon we work hard to earn and maintain customer trust, meaning that safety is a top priority for us. Last year, we invested more than $900 million to protect our stores and our customers, building robust safety and compliance programs, which includes the continual review of our controls to ensure appropriate product information is displayed. While we note that there is no suggestion that any product purchased on any Amazon store was involved in Ms. Abukar’s death, we are willing to explain our processes in relation to the sale of e- scooters. Specifically:
- we include a warning on product pages for e-scooters which makes clear that they are prohibited from use in any public road or space in the UK;
- we make this warning prominent by ensuring it appears in the “About this Item” section and is highlighted for customers’ attention using the heading “Important note” in bold font;
- the warning also includes a link to the latest government guidance;
- when we identify that an e-scooter advertisement may suggest the product’s use on public roads or streets, we send our UK selling partners detailed communications telling them to remove such references, including removing pictures encouraging potentially illegal use by customers; and
- we publish education reminding all selling partners to check if there are local legal restrictions in relation to the use of e-mobility devices on public roads or spaces. We trust this is helpful and again express our sincere condolences to Ms. Abukar’s family for their tragic loss. Please do let me know if you require any further information.
escooterclinic
18 Dec 2022
Response received
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Dear Stephanie,  Thank you for reaching out. I am sad to learn about that event that I was unaware of before you reached out to us. The user of the vehicle was underage, recklessly driving, on the wrong side of the road, without protection. The fact that she was using a scooter is completely irrelevant, she could have been using a bicycle as well, or just running on her own legs. We would advise that the government takes the important decision of legalising the scooters, to introduce proper laws and regulations. Protective gear should be compulsory as well as third-party insurance.  The government has been delaying the legislation at the same time allowing rented scooters on the street. That causes a lot of confusion. The UK commuters have spoken and have expressed interest in a new, eco-friendly, personal transport being properly introduced and legalised in the country. Sadly the incident is not at the fault of the vehicle but the user. Kind regards, Patryk Radek
Selfridges
13 Jan 2023
Response received
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Dear Sir

Re: Regulation 28 Report to Prevent Future Deaths

I write in response to your letter addressed to Selfridges Group Managing Director,

(since departed from Selfridges Group), received on 15 December 2022. This letter, setting out a Regulation 28 (Preventing Future Deaths) report, requests our response as a retailer which sells e-scooters. I write to you as General Counsel and a director of Selfridges Retail Limited, which trades as Selfridges (and which is part of Selfridges Group).

I confirm that Selfridges and its directors fully appreciate the gravity of the matter addressed in the report and we recognise that receiving this report provides us with an opportunity to consider what role we, as retailers, can play in guarding against future unavoidable deaths in similar circumstances. An avoidable death is always a tragedy and all the more so where this involves the death of a child.

Selfridges is a responsible retailer and, in particular, we recognise our responsibility to ensure that when we sell e-scooters we should make it clear to customers that an e- scooter may not be lawfully ridden on the public highway.

Selfridges first received a communication on this topic in November 2020, in a joint letter from the Mayor of London and the Metropolitan Police requesting retailers provide accurate information to make customers aware that private e-scooters are illegal on public roads, pavements and other public places. In response, Selfridges reviewed where these products were sold, whether offered directly by Selfridges or via concession partners, and addressed this issue to ensure there was a clearly visible message to customers (in stores and on the website).

Since 2020, and particularly in the run up to the peak trading period around Christmas, Selfridges Legal team has reviewed and reminded stores and digital trading teams about this matter and the need for suitable communications to customers.

In November 2022, Selfridges received a similar letter from the Mayor of London and the Metropolitan Police, reminding retailers of the legal position concerning e-scooters, whilst the Government continued to consider whether to alter their legal status. Once again, Selfridges Legal team issued reminders and a guidance note to stores and digital teams to ensure that where e-scooters are sold there are suitable communications to customers, confirming they remain illegal to be ridden on public roads and other public places.

In addition, Selfridges Technology team was asked to support with exploring what systems-based solutions might be added in future, such as a flag against a product like this to remind all teams dealing with the product that customer safety advisory requirements or other restrictions exist and should be checked and/or observed.

In early December 2022, Selfridges received a further similar letter from the Government’s Department for Transport addressed to Selfridges Managing Director. The above actions were already underway.

Following receipt of this Regulation 28 (Preventing Future Deaths) report served by His Majesty’s Coroner Mr Irvine on Selfridges, the above actions have been reviewed and the matter has been raised, discussed and noted at a meeting of Selfridges Executive Committee (meeting held in January 2023).

We hope that these steps taken by Selfridges, which are ongoing in nature, demonstrate the seriousness with which Selfridges and its directors take their commitments as a responsible retailer in relation to this matter.

Selfridges looks forward to any forthcoming legislation or guidance addressing e- scooters and their use.
Halfords
26 Jan 2023
Response received
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Dear Mr Irvine, Report Pursuant to Regulation 28 of The Coroners (Investigations) Regulations 2013 Further to the Report you issued in your capacity as the Coroner who presided over the inquest into the tragic death of Fatima Abukar and which you sent to Halfords and other major retailers of e-scooters on 15 December, we make the following comments in reply. You asked for information on the actions that have either been taken, or are proposed to be taken, regarding the warnings about the illegal use of e-scooters. As you may be aware, Halfords Group Plc, is the UK’s largest retailer of motoring and cycling products and services and we agree that such warnings are vital for the safety of riders. We can confirm that we advise potential buyers about the current legal position in regard to the use of e-scooters (which is that e-scooters can only be used on private land and even then, only with the owner’s consent). We provide this advice at every stage of the sales process, both in store and online. The steps we take also include:
• Prominent signage next to e-scooters in stores, clearly explaining the law, including that they are not to be used on public roads;

• A clear legal statement on all e-scooter price tickets;

• A clear legal statement on all e-scooter warranties;

• the training we provide to our sales colleagues to outline explicitly the legal position when the customer considers buying an e-scooter (this includes drawing attention to the signage, as well as advising them that, if they fail to adhere to these rules, they would face a criminal offence and possible prosecution);

• that our colleagues are tutored in this process and made aware of this as it is the very first agenda point when they undertake the e-learning e-scooter module of their training;

• having till rolls and cash registers which also have pop-up warnings to remind our colleagues to again inform customers of the law at the point of sale;

• that the headers on all e-scooter product detail pages state that it is illegal to use them on a public road, pavement or cycle lane; and,

• that wherever an e-scooter is referenced in a blog we add our standard wording about the how e-scooter may be used legally.

We started selling e-scooters in April 2019, and have always recognised the need for clear advice regarding the law which applies to the use of e-scooters. For example, after Government Ministers brought forward the introduction of trial hire schemes in 2020, which led to increased interest in e- scooters, we made sure that the detailed guidance we provided (i.e. as set out above) was updated. As a result, Halfords has previously been recognised as a responsible retailer of e-scooters by the then Secretary of State for Business1 and a Police and Crime Commissioner2. The steps we take are intended to ensure that throughout their purchasing journey every customer is fully aware of the law that applies in this area, and we consider that this shows how seriously we take our responsibilities in this regard. We work hard to maintain our reputation as a responsible retailer of these products. This is why we constantly review the way we inform customers about the law; why we have updated, and will continue to update, our signage and why we adapt our processes extremely quickly if we identify improvements that can be made. We have, for example, just recently sent a communication to our digital teams to make sure they maintain the prominence of messages about the current law, in our on-line and social media platforms, and we have asked them to see if they can find ways of to make this even clearer. We have also advised the Government that if there is to be a Transport Bill which might address the wider legalisation e-scooters, any change in the law should be introduced in a measured and controlled manner. For instance, we have advocated for a maximum speed limit of 15.5mph, as this would harmonise e-scooters with e-bikes and thus avoid a higher speed differential that could prove dangerous. Another example is in regard to lights and reflectors. We believe that any rules introduced should be consistent with those required of cyclists, and we note that the Highway Code for cyclists says: ‘At night your cycle must have white front and red rear lights lit. It must also be fitted with a red rear reflector.’

1 Q239 https://committees.parliament.uk/oralevidence/10158/pdf/ 2 See blue highlighted comment by Kent PCC Matthew Scott https://www.thesun.co.uk/news/15683358/gunmen- e-scooters-ride-by-shootings/

Finally, we note that the Chief Coroner might wish to publish this response in a completed, redacted or summarised form and that you and/or the Chief Coroner might also wish to send this response to any person to whom it might be useful or of interest. We think it could be beneficial for this response to be circulated, especially if doing so progresses and informs the debate in this area, and so we do not object to that occurring in these circumstances. I fully understand the seriousness of this tragic case and the concerns raised and so I hope this response meets your requirements. If you need further information, please do not hesitate to contact me.
Metropolitan Police
3 Feb 2023
Response received
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PROFESSIONALISM HQ

Mr G Irvine

HM Senior Coroner

Deputy Assistant Commissioner East London

New Scotland Yard

Walthamstow Coroner’s Court

Victoria Embankment Queens Road London Walthamstow

SW1A 2JL

London E17 8QP

Date: 03.02.2023

I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the Metropolitan Police Service (MPS). I write to provide the response on behalf of the Commissioner of Police of the Metropolis to the matters of concern addressed to the MPS in the Report to Prevent Future Deaths dated 14th December 2022.

On behalf of the MPS may I first of all express my sincere condolences to Ms Abukar’s family. Our thoughts and sympathies are very much with them.

Matter of Concern 1

Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London's streets, riding them on public roads is unlawful.

Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022. The reduction is attributable to a change in policy introduced in November 2021.

MPS Response

The MPS is aware of the use of illegal e-scooters on London’s roads and we continue to take a proportionate policing response to their use. In 2021, the MPS published information on the MPS public website (https://www.met.police.uk/advice/advice-and-information/rs/road- safety/advice-escooters/) titled ‘Advice on using e-scooters’. This article clearly states that ‘it is not currently possible to get insurance for privately owned e-scooters, which means it's illegal to use them on the road or in public spaces. If you're using a private e-scooter you risk the vehicle being seized under S.165 Road Traffic Act 1988 for no insurance’. This messaging was also re-enforced on numerous occasions by the MPS Roads and Transport Policing Command (RTPC) in their communication with members of the public via their MPS Twitter account. In addition, other Basic Command Units have used social media to communicate the law and to demonstrate how they have seized a number of e-scooters.

The MPS updated their policy titled “Seizure of vehicles for No Licence and Insurance Standard Operating Procedure” which covers the seizure and enforcement of offences connected with the use of illegal e-scooters, in September 2021. There was no specific update to the policy concerning the seizure of E-scooters at this time. An element of discretion has applied in relation to the seizure of e-scooters and other non-standard mechanically propelled vehicles for a number of years prior to this by way of the following paragraph: “Discretion is required when policing personal transporters, particularly when dealing with juveniles. It should take an educational, advisory, and non-confrontational approach when enforcing this legislation. Guidance should be given to users about where they can and cannot use these devices and to ride responsibly.” In 2021, the MPS had an existing policy for dealing with illegal e-scooter use, called Operation Hornet. This policy, issued on the MPS internal website some years earlier, already directed a proportionate response to dealing with the illegal use of these devices. In November 2021, due to ever increasing seizures and reporting of offences relating to these devices in London, the MPS Roads and Transport Policing Command issued direction re-emphasising the need for a graduated and proportionate response balancing the need to protect the public whilst not unnecessarily criminalising the public in a complex area of roads policing legislation (private e-scooters were illegal at this time but council approved ones on a trial were routinely on the roads causing confusion with the public at large). This direction, in line with other areas of policing, confirmed that each offence should be dealt with on a case by case basis, and where appropriate officers should seek to engage, explain and encourage anyone using an E-scooter in public to discontinue riding the device immediately (the engage, explain and encourage approach was borrowed from the national and widely publicised policing stance on COVID enforcement). Where the person stopped was however committing other offences or putting the public in danger, then this would then be robustly enforced, including seizure of the device, issuing a TOR (Traffic Offence Report) or arresting the rider.

In June 2022, the policy was further amended to re-inforce this direction as follows:

“6.5. It is important to remind users that it is unlawful to use these vehicles on pavements and public roads.

6.6. Discretion is required when policing personal transporters, particularly when dealing with juveniles. It should take an educational, advisory, and non- confrontational approach when enforcing this legislation. Guidance should be given to users about where they can and cannot use these devices and to ride responsibly.

6.7 If this guidance is ignored, the vehicle is involved in criminality, behaviour that put the wider public at risk, or the user has committed any offences other than Sec 164/165 Road Traffic Act, officers have the power to seize devices and report users for prosecution in line with the ‘e-scooter flowchart’. If seized, they can be taken to a car pound using the station van.

6.8. If the offender is a juvenile, consideration should be made about contacting the adult responsible for the juvenile and considering any offences of allowing or permitting the use of the personal transporter.

6.9 Prior to July 2022 the Met exercised its discretion and waived some of the release conditions for production of a valid certificate of insurance and/or a valid driving licence when reclaiming of non-standard mechanically propelled vehicle that had been seized under Sec 165A RTA 1988 at the Met car pounds. This was to afford the owner or registered keeper the ability to reclaim the vehicle. However, as of July 2022 the Met

will no longer waive these conditions and instead will require compliance with the full release conditions as specified in Regulation 5 of the Road Traffic Act 1988 (Retention and Disposal of Seized Motor Vehicles) Regulations 2005, as they do with other motor vehicles seized under the same powers. These requirements include the production of a valid certificate of insurance, a valid driving licence, payment of the statutory fees and they must satisfy the authorised person that they are either the registered keeper or owner of the vehicle”.

A copy of the e-scooter flow chart is appended to this response.

An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.

It is not accepted by the MPS that there is a correlation between the legal enforcement of e- scooters and the number of deaths. It is not understood that any such evidence was presented to the Coroner during the inquest.

Matter of Concern 2

Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.

The regulations, and parameters, regarding the use of licenced scooters in e-scooter trials, and the use of head protection, was a policy decision made by the Department for Transport, and Transport for London, for their use in London. They are best placed to comments on the rationale for this decision.

The MPS support the use of protective headwear and have suggested this on many occasions to the DfT and TfL, as confirmed by the evidence of Chief Superintendent Ovens during the inquest.

Matter of Concern 3

Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.

For the last three years on the approach to Christmas, the MPS has written a joint letter with Will Norman (TfL Walking and Cycling Commissioner) to e-scooter retailers asking them to ensure prominent signs are displayed at the point of sale to remind customers about the legality of e-scooters.

I trust this clarifies the position the MPS took in relation to the reduction in the seizure of e- scooters in 2022, however, please do not hesitate to contact me should you have any queries.
Harrods
6 Feb 2023
Response received
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Dear Mr Irvine,

RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS - Inquest into the death of Fatima Abukar

We write further to your Regulation 28 report dated 14th December 2022.

Firstly, please may we extend our sincerest condolences to the family and loved ones of Fatima Abukar, and all others who have tragically lost their lives whilst using an E-Scooter.

We are saddened to learn the truly concerning statistics advised under section 5 of your report and remain committed to doing what we can as a business to ensure the safety and wellbeing of all of our customers.

At the time of writing, customers are advised at the point of sale that E-Scooters purchased from Harrods are not suitable for road use and text is added to their sales receipts to reflect this. Furthermore, we routinely recommend to customers that they purchase helmets for use with their E-Scooters. Helmets are available for sale in the Technology department and are displayed alongside the E- Scooters. We are also implementing age verification checks at the point of sale to ensure that E-Scooters are not sold to persons under the age of 18.

Further to the above, we are now taking steps to prepare notices to be displayed in the Technology department and on our online retail website, harrods.com. Such notices will make clear that it is illegal to use an E-Scooter on a public road and in spaces that are set aside for use by pedestrians, cyclists and horse-riders

(including the pavement and cycle lanes). We enclose a copy of the notice in the Schedule to this letter.

The notices will be prominently displayed (i) in the area(s) containing E-Scooters within the Technology department in Harrods’ Knightsbridge store, and (ii) on product pages for E-Scooters on harrods.com. Furthermore, customers purchasing an E-Scooter in store will be directed to read the content of the notice before completing any purchase. We anticipate these notices will be on display and clearly visible for customers by 10th February 2023.

We trust that the above clearly sets out the actions that we have taken and will be taking in the near future (along with our anticipated timeline for implementing the same). However, please do not hesitate to contact us if we can assist any further.
Transport for London
8 Feb 2023
Response received
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Dear Mr Irvine

Regulation 28 report: Report to prevent future deaths – Fatima Abukar

I write on behalf of Transport for London (‘TfL’) and the Mayor of London with regard to the Senior Coroner’s Prevention of Future Deaths (‘PFD’) report dated 14 December 2022 following the inquest arising from the death of Fatima Abukar. I am personally very sorry to hear of the tragic death of Fatima Abukar and wish to express my sincere condolences and those of TfL to the family and friends of Fatima. TfL and the Mayor of London were not interested persons at the inquest and have not previously been contacted in relation to this tragic incident.

The Regulation 28 report refers to three areas of concern being:

1. “Evidence in this inquest confirmed that since 2019, there have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful. Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022. The reduction is attributable to a change in policy introduced in November 2021. An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 &2 of 2022 is more than double that of Q1 & 2 of 2021.
2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.

3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.” This is the response from both TfL and the Mayor of London. In London, as with other parts of the UK, it is illegal to use privately-owned e-scooters on public roads.

TfL and the Mayor want to explore new, environmentally friendly forms of transport that can be used to reduce road congestion in London. However, it is recognised that any alternatives must be safe for both users and non-users alike.

TfL RESTRICTED Since June 2021, TfL has been running a rental e-scooter trial which has been approved by the Department for Transport (‘DfT’) and is part of a national programme of trials intended to inform any legislative approach to altering the legal status of these vehicles which the Government may choose to pursue. Anonymised data from the rental scheme is being used to assess how e-scooters could make a positive contribution to transport in London.

Rental e-scooters are the only way to legally ride an e-scooter on public roads or in other public places within London, and this is limited to specific boroughs. Since the trial launched, it has expanded to cover ten boroughs, there are more than 500 designated parking locations and the total fleet is now over 4,500 e-scooters.

The DfT has provided updated guidance which allows existing trials in the UK to be extended to 31 May 2024, enabling local authorities to continue to test the vehicles in a safe and legal way. The e-scooter rental trial is part of a wider effort by TfL, London Councils, London boroughs and the Government to enable people to use new and greener forms of transport.

TfL is working closely with the relevant London borough councils and has made Traffic Regulation Orders to allow the use of e-scooters on TfL cycle tracks within the participating boroughs. It is illegal to ride any e-scooter on the pavement however, and to do so carries the risk of fines and prosecution. This could include a £300 fixed penalty notice, six penalty points on a rider’s driving licence for riding with no insurance, and seizure of the e-scooter.

The current phase of the trial is expected to run until Autumn 2023. Through the competitive procurement process for the new phase of London's rental e-scooter trial which is currently under way, operators for the second phase (to 31 May 2024) will be selected on their ability to meet strict safety requirements and high operating standards. For example, rental e-scooters must have specific safety features installed including speeds limited to 12.5mph and lights that are always on throughout any rental (see further safety features below).

Safety is TfL’s priority. The trial will help TfL to better understand how e-scooters can be used safely in London and how we should develop policy. London’s learnings and data from the trial will help to shape national legislation in the future. TfL is taking a number of steps to ensure that anyone using a rental e-scooter rides safely and follows the rules of the road as well as guidance from the rental operator. DfT’s national standards include requirements for all vehicles to be identifiable by their unique number plates vehicles, to have kick-stands, as well as strict parking requirements to prevent them from being trip hazards when not in use. TfL’s safety standards go beyond the DfT’s national standards and include:

• Riders must be 18 or over and hold at least a provisional driving licence
• The speed limit of trial e-scooters is capped at 12.5mph (as opposed to the national maximum of 15.5mph, which is often the speed that e-scooters available for private purchase can reach). They will automatically reduce speed to 8mph in 'go slow' areas. The trial e-scooters also come to a safe stop in 'no-go' zones to ensure they can be ridden safely
• All first-time riders must do mandatory training on how to ride safely in London
• The trial e-scooters are maintained to a high level and have large wheels to help navigate road surfaces more easily
• Lights at the front and rear of the vehicles are always on throughout any rental
• In the procurement for the second phase of the trial, a minimum wheel size has been added to the vehicle specification.

TfL and operators also provide safety guidance and tips on how to ride rental e-scooters safely and avoid serious injury to any road users. This includes encouraging all riders to use protective equipment while using e-scooters including wearing a helmet. The wearing of helmets is not required by DfT for the trials, however.

TfL RESTRICTED

Reports of poor rider behaviour are taken seriously and the operators have warned or banned more than 200 people to date.

In addition, in the lead up to Christmas, with the expected increase in the sale of private e- scooters, , London’s Walking and Cycling Commissioner, and Metropolitan Police Service (‘MPS’) Commander, , jointly wrote to retailers to remind them of their duty to make customers aware of the law regarding the use of private e-scooters. TfL and the MPS have also jointly run a communications campaign to raise public awareness that private e-scooters are illegal.

In 2022, the Government announced plans to create a new vehicle category in legislation, in which e-scooters would be included. TfL would welcome such legislation which has the potential to make important improvements to the safety of private e-scooters, which are not presently constructed to any regulatory standards. We hope the legislation enabling this will be introduced without further delay. TfL continues to work with the MPS, and City of London Police (‘CoLP’) to engage with users of privately-owned e-scooters and, where necessary, the MPS and CoLP will use their enforcement powers to help keep Londoners safe. We will continue to monitor the data from the rental e-scooter trial and support the introduction of legislation to ensure the safety of private e-scooters.
Onboards
9 Feb 2023
Response received
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Dear Graeme Irvine, Senior Coroner,for the coroner area of East London Onboards is deeply sorry to hear what has happened to Ms Abukar in this unfortunately incident onBoards, as a company, proactively promote safety among our customers, electric bicycles and scooters users Below please find a list of measurements we have in place in order to inform clients and users about how to maximise safety while riding these products
1. We have helmets displayed among our bikes and scooters in order to bring awareness of the use of such products
2. We offer discount in helmets when they are bought together with bikes and scooters
3. When liaising with clients in our shop we encourage the use of helmets and high vests clothing and try to bring awareness of the importance of using such safety devices
4. All our lifestyle pictures in our website and social media have riders always appear wearing helmets
5. We do not sell electric scooters to persons under 18 years old
6. In the scooters section of our shop we have displayed a sign that explicitly mentions the illegality of using electric scooter that are not from rental companies in public roads
7. All invoices specifically mentions the illegality of using private electric scooters in public roads, footpaths and cycle lanes
8. The footer of all our web pages includes the same disclaimer Although no effort is enough to assure safety among rides, we are committed to always do as much as possible in order to bring awareness, inform and promote safety Should you consider that other measures should be in place please let us know as we are always willing to collaborate and improve safety Regards Director of OnBoards
Department for Transport
10 Feb 2023
Response received
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Dear Mr Irvine, I was sorry to hear of Fatima Abukar’s tragic death and would like to thank you for your investigation and the issues you have highlighted. I am writing to address your concerns about the marketing practices of e- scooter retailers and riders of hired scooters not being required to wear helmets. My Rt Hon colleague, the Secretary of State for the Home Department will write to you with regards to your concerns about the enforcement and seizure of privately owned e-scooters being used illegally on public land. As your report highlights, e-scooters outside of the rental trials can only be used on private land with the landowner’s permission and they remain illegal to use on public land. Your report highlights the issue of some manufacturers and retailers of e-scooters in England and Wales do not always provide prominent warnings that these private e-scooters are illegal to use on public land. This is an issue the Department is aware of and as a result, last summer the Driver and Vehicle Standards Agency (DVSA) began market surveillance work. To date, approximately 60 retailers have been found to be selling without the full and proper warnings. The DVSA has followed this up with warning letters to remind retailers of their obligations and we have already seen some changes in industry behaviour, with misleading imaging removed and the correct statement of the current law. Under s65 of the Road Traffic Act 1988, the DVSA can take further action against retailers that remain non-compliant which may lead to prosecution of individuals and businesses. Ministerial colleagues at the Department for Transport, most recently the Minister of State for Decarbonisation and Technology in December 2022, have also written to micromobility retailers reminding them of the law. These letters drew specific attention to the advertising concerns in each case. From the Secretary of State The Rt Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR

Web site: www.gov.uk/dft

The e-scooter trials were launched in July 2020 and are currently live in 25 areas across England. These trials are designed to assess the safety of e- scooters, their potential benefits and their impact on public space to help us consider options for future regulation of e-scooters. Cycle helmets are recommended for the trials but are not a requirement, as is the case for bicycles and electrically-assisted pedal cycles. In February 2022 we issued updated guidance to all local authorities and e-scooter operators that further encouraged them to provide helmets and incentivise their use. Whilst this tragic incident did not happen within the trials, I recognise this is an important consideration as the Government plans to bring forward legislation that will allow e-scooters to be regulated. As part of this, we will consult on a range of topics, including helmet wearing.
Evolve Skateboard
Response received
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ACCESSIBLE STREETS EVOLVE SKATEBOARDS RESPONSE TO CORONER’S REPORT REGULATION 28

The aim of our response is to provide an outline of the actions currently taken as a company to minimise and alleviate incidents and accidents involving use of our product. In addition, we have taken this opportunity to put forward constructive guidelines for the Coroner’s review and consideration, that are in line with contemporary personal mobility device (PMD) guidelines globally, that address the safe use of Electric Skateboards within public spaces (roads and shared footpaths), and are enforceable, while still allowing the user to enjoy the product and be active within the community. SAFE USE OF EVOLVE SKATEBOARDS Evolve Skateboards actively encourages and reinforces the safe and responsible use of our product through pre and post-sale activity. As a top-line summary, this includes, though is not limited to; The reinforcement of safe use guidelines and principles as part of customer service practice and after sales documentation eg user manual. Reference to requirements to wear a helmet when using our product as part of FAQ’s on our website. Reference to the responsibility of customer’s to ensure compliance with the safety and legal requirements in their jurisdiction as part of our store policy provided on our website. Founding member of a PMD safety group advising the Land Transport Safety and Regulation Bureau, within the Department of Transport and Main Roads in Queensland, Australia, culminating in the legislation for use of PMD’s in the state. In addition, Evolve Skateboards is in the process of conducting a review of its current practice, globally, with regard to safety and legal compliance. This includes the engagement of legal and industry professionals to provide contemporary advice to ensure adherence to standards in each market we operate in. We expect this to be completed and rolled out, globally, including in the UK, by June 30, 2023.

GUIDELINES FOR THE SAFE USE OF PMD’S DEVICE POWER OUTPUT The most effective solution for the frontline police officer to police electric skateboards/scooters is by way of restricted ‘Speed Limits’ for the person controlling the device and a ‘Size and weight’ category of the device, not by the ‘Power Output’ of the device. As battery and motor technology are changing rapidly within the PMD marketplace, they are becoming smaller, lighter, more discrete and more powerful year by year. Trying to police these rapid increases in technology will be almost impossible for law enforcement, especially for the police officers on the front line who are not trained engineers (nor should they be). SPEED LIMITS Just like motor vehicles used on our roads have restricted speed limits for all types of cars from the average family car to the super car enthusiast, electric skateboards/scooters should have a safe Speed Limit restriction that allows for safe use within our public spaces, yet still allows the user to enjoy the product. In this respect, we suggest the following be implemented in the UK, which has been adopted in the state of Queensland, Australia: 1- A maximum speed limit of 25kph (15mph) for the person using the device. This speed limit is restricted to roads of 50kph (31mph) or less and must be ridden on the sides of roads or in cycle paths if applicable. 2- A maximum speed limit of 15kph (9mph) on share footpaths, however 10kph (jogging pace) in environments where there are high density people on the footpath or road. This is common sense riding and would be applicable to busy inner city spaces. 3- Police are able to issue ‘speeding tickets/fines’ if the user goes over set speed limit.

SIZE AND WEIGHT OF DEVICE Electric skateboards are very small in size and weight with most electric skateboards weighing in at less than 8kg. As electric skateboards sit very low to the ground and have a maximum height of 17.5cm (most are 10cm in height), this makes the device very safe for all pedestrians if ever there was a collision compared to a normal bike, scooter or E-bike, as the device only reaches ankle height. However, we would suggest the following size and weight restrictions for electric skateboards be used on shared roads and footpaths; 1- Weigh less than 25kg. 2- Have a width less than 60cm. 3- Have a length less than 1.5m.

SHARED FOOTPATHS, ROADS AND CYCLE WAYS The safe use of electric skateboards/scooters within the public space is very important, to which, we suggest the following principles be applied: 1- Can only be used roads that have a maximum speed limit of 50kph (31mph) or less and to be used on the sides of the roads or cycle lanes. 2- Can be use on shared footpaths with a speed limit of 10kph (6mph) on inner city footpaths, all other footpaths 15kph (9mph). 3- The electric skateboard/scooter must be under 25kgs in weight and less than 1.5M in length and less than 60cm in width. 4- Common sense and courtesy must be applied when there are pedestrians on the path at the same time and pedestrians always have right of way. RIDING AT NIGHT Riding at night will always pose a risk, especially if riding on dark roads. In this respect, we suggest the following: The electric skateboards must have front and rear safety lights installed and turned on if being ridden at night. HELMETS Helmets save lives, with that said we suggest that it is compulsory to wear a Helmet when riding an electric skateboard/scooter and the helmet must be rated to AS/NZS 2063:2008

CONCLUSION The above suggestions are for the Coroner’s review and consideration with regard to using Electric Skateboards/Scooters within shared roads and footpaths, and forms the complete response of Evolve Skateboards UK, to the Coroner’s Report Regulation 28. We believe it is very important to have a set of guidelines that are enforceable and not going to go out of date within a couple of years. Common sense always must remain the responsibility of the user, just the same way people use cars with speed limit restrictions. If the measures are not followed, then law enforcement has the right to issue fines accordingly. Personal mobility devices will become more and more popular in the future due to climate change and our communities’ expectations of Government to provide legislative frameworks for electric vehicle and device use. As governments focus more on smartening up their cities, they are looking for viable transportation solutions that can decrease traffic congestion while also creating a cleaner environment for the entire community. Personal mobility devices are part of this solution therefore, creating a safe environment to use personal mobility devices in a shared space is increasingly important. eMOBILITY CHANGES IN THE UK WITH ELECTROHEADS

PMD QUEENSLAND (AUSTRALIA) ROAD RULES

Penalties Exceeding the speed limit: More than ˜°ˆ˙
* Rules Exceeding the speed limit: More than ˜˝˘˘
* for riders Exceeding the speed limit: More than ˜ˇ5˙
* Exceeding the speed limit: More ˜5˛˘ than Not wearing a helmet: More than ˜°ˆ˙
* Scan the QR code for further details, Doubling: including videos covering these key rules.: More than ˜°ˆ˙
* streetsmarts.initiatives.qld.gov.au/pmd/get-the-facts Using a mobile phone: More than ˜°˙˛˙
* Drinking liquor while riding: More than ˜ˆˇ˘
* Riding on a prohibited road: More than ˜°˛˝˙
*
*Fines can increase from 1 July each year so check qld.gov.au/transport/safety/ÿnes/personal-mobility-device­ riding-rules-and-ÿnes for current amounts. >˜° km/h over ˛°˝˜° km/h over ˙ˆ˝˛° km/h over ˙˝˙˜ km/h over Rules for personal mobility devices in Queensland including:
• E-scooters
• E-skateboards
• E-unicycles

Key rules to follow Reduced speed on footpaths Maximum speed limit ˜˝+ PMD riders must be Speed limit of ˝˜km/h on footpaths and Speed limit of ˜°km/h on bike paths and roads. ˜° years old or older shared paths, unless otherwise signed. ˝˜ˆ˝°'s may ride, but must be supervised by an adult. Know where you can ride Always wear a helmet Leave your phone alone
• Paths – footpaths, shared paths,
• Approved bicycle or motorcycle helmets when riding are ok. separated paths and bike paths.
• Hand-held phone use, or resting it on any
• Local streets (speed limit of °˙km/h or less,
• Helmet straps must be fastened. part of your body is illegal while riding. no dividing line).
• Additional protective gear like elbow
• Using a phone in a cradle mounted to and knee pads and high visibility clothing handlebars is ok if you are not distracted.
• On-road bike lanes (speed limit of °˙km/h is also recommended. or less, or where the bike lane is physically separated from the road). Parking General road rules
• Park your PMD in designated parking areas. apply for PMD riders Otherwise, park on the kerbside.
• Don’t block the path and keep clear of No doubling
• Obey tra˛c lights and signs kerb ramps, building access and exits,
• Follow general road rules regarding Passengers are not allowed, regardless tactile ground surface indicators and giving way and making turns of age or size. This includes no children pedestrian push buttons. doubling with parents.
• Indicate when changing direction
• Do the right thing. Poor parking creates
– either by hand signals or indicators. problems for other path users, particularly people with a disability. Warn pedestrians Use lights and Don't drink and ride as you approach reflectors a˛er dark Devices with handlebars must have a bell.
Report Sections
Investigation and Inquest
On 22nd March 2022 this Court commenced an investigation into the death of Fatima Abukar age 14 years . The investigation concluded at the end of the inquest on 13th December 2022. I arrived at a short form conclusion of Road Traffic Collision. Ms Abukar's medical cause of death was determined as; 1 a Head Injury 1 b Blunt Force Trauma (Road Traffic Collision)
Circumstances of the Death
Fatima Abukar was a 14 year old girl who died due to catastrophic head injuries sustained in a road traffic collision . Ms Abukar was observed to ride a battery-powered e-scooter in a southerly direction on the west pavement of Green Street, East Ham. Ms Abukar was travelling at a speed not less than 11 mph , she not wearing any safety equipment. Ms Abukar left the pavement and entered the northbound carriageway of the road , against the flow of traffic. Ms Abukar bore left, over the central markings of the road and joined the southbound carriageway travelling alongside a mini-bus. The e-scooter struck the off-side of the mini-bus, Ms Abukar lost control and fell beneath the wheels of the mini-bus.

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.