Dear Mr Pears Re:_Inquest touching the death of Mr Ernest Charles HAPRER Inquest heldon the May 2014at Coroners Court_Ampthill In response to the matters of concern raised in the Regulation 28 Report to Prevent Future Deaths dated 12 May 2014, write to confirm actions taken by Bedford Borough Council. The matters of concern were described as follows That it was possible to fall between the safety barrier and the back of the vehicle_ 2 That the detail of a passenger's health andlor mobility (for the purpose of risk assessing the passenger's safety when accessing and egressing the vehicle) is dependent upon information supplied voluntarily by the passenger andlor his family rather than by a formal assessment Bedford Borough Council has taken the matters of concern very seriously and am abie to respond to each point io describe the actions aiready taken and those in the process of being undertaken. Concern raised: That it was possible to fall between the safety barrier and the back of the vehicle. Action_TakenIProposed: Devices have been retro- fitted to the doors on all Ford Transit vehicles, the type of vehicle the accident occurred on. This blocks the gaps between the back of the vehicle and the handrail. Dosat

We are now talking to manufacturers and the Driver and Vehicle Standard Agency to see if there are any additional measures that can be introduced to further improve safety. In addition to through the Association of Transport Co-ordinating Officers, we are making other Local Authorities aware of our experiences. Concern raised: 1 That details of passengers health andlor mobility (for the purpose of risk assessing and egressing the vehicle) is dependent upon information supplied voluntarily by the passenger andlor his family rather than by former assessment: Action Taken/ Proposed: redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting onioff vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are produced on the Council's health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14
2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification_ A newly redesigned Client Transport Referral has also been devised by the Transport Operations Group, in conjunction with Adult Services_ The form which has been re-designed through consultation with our Occupational Therapists will focus on the person's functional ability and will be used for initial transport requests, as well as requests for reinstatement of the transport service when there has been a break in service due to medical reasons_ This new form will capture information taken from the person/family member and will help to determine whether the reinstatement of the previous transport arrangements are appropriate. The new proposed process also includes a requirement for a client specific risk assessment to be conducted by the Social Care Transport Team for every client who is not ambulant The redesigned referral will be introduced by 14 July 2014. A system has been produced and this will be implemented by 14 2014,to ensure that any information provided verbally by Centre staff to vehicle staff on arrival regarding the client is also provided in a written format The written form includes guidance notes for staff with regard to what type of information must be relayed_ If any concerns are noted during the at a Centre, the centre staff will verbally this information to the transport staff on arrival, backed up with the written form; copies of which will also be provided to the Social Workers and Social Transport Bedford Borough Council has deleted historical information its Routewise forms provided to staff working on the vehicle to make current information regarding passengers clearer to staff. This ensures that the driver and passenger assistant have the most current information on passengers_ this, being July Form form July Day day Day day relay Care Team: from

Bedford Borough Council have taken the actions outlined in this response and have also identified a range of proposed actions to prevent any further deaths through injury from falling from a vehicle. In conclusion, would like to place on record the Councils sincere apologies for this unfortunate incident.