Alfie Tollett

PFD Report All Responded Ref: 2024-0471
Date of Report 27 August 2024
Coroner Deborah Archer
Response Deadline ✓ from report 22 October 2024
All 1 response received · Deadline: 22 Oct 2024
Response Status
Responses 1 of 1
56-Day Deadline 22 Oct 2024
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) Although it is accepted that this death was accidental , during the inquest the following information came to light as a result of the investigating police officer giving evidence : (2) There were a number of errors that were made by the driver which caused or contributed to the death . These were  Wrongly placing the car in drive instead of reverse  Failing to look down at the camera and pressing the button to move forward by touch alone  Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged  Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed  Failing to press the brake at any time . (3 ) However , these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer’s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted to the fact that he had pushed the incorrect button on the 3 button console .
Responses
Jaguar
22 Oct 2024
Jaguar Land Rover disputes the need for changes to its vehicle design, stating that the current gear transmission control unit and alert strategy meet all legal safety requirements. Their review of vehicle data suggested driver error, including 81% throttle command and lack of typical steering adjustment. AI summary
View full response
Dear Coroner RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) This is Jaguar Land Rover Limited' s ("JLR") response to vour report made, under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 27th August 2024 (the 'Notice following the death of Alfie Tollett on 19th February 2023. We would like to express our deepest sympathies to the family and friends of Alfie, following his untimely death: Following receipt of the Notice, JLR has reviewed this incident, and the data from the vehicle involved: Vehicle involvedin incident and assistance provided to Police The vehicle involved in the incident was a Jaguar |-Pace, with Vehicle Identification Numbet (the "Vehicle built on 1st December 2021 and purchased by Jon 14th February 2022. Mrs Thompson was thefirst ownerofthe Vehicle, which displayed the registration the wife ofl We understand from the Notice, that was driving the Vehicle when the incident occurred on 19th February 2023. Whilst the Vehicle has been in service JLR has not been informedof any roadside assists, defects or warranty claims_ The Telematics Data Request ( "TDR"= process is the single route into JLR for all law enforcement data requests in respect of vehicles_ The TDR process ensures that the request is made by an individual authorised to make such requestsandthe relevantlegalauthorities have been obtained inline with the Data Protection Act 2018. JLR supports law enforcement agencies on a regular basis and provides assistance to aid in investigations_ On 28th March 2023, Devonand Cornwall Police informed JLR via the TDR process,of a fatal collision, and asked for supportin retrieving data from the Vehicle'srestraints controlmodule. As partof the TDR process Devon and Cornwall Police supplied a Production Order to JLR which was signed by the Circuit Judge on 14th April 2023. This granted permission for disclosure of the 'Full download of the Telematics data control unit relating to Jaguar I-Pac (registration vehicle identification number (VIN) containing full event data for Sunday 19h February 2023 between 0001-2359 hours JLR Abbey Road, Whitley, Coventry; CV3 4LF 44 (012476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER UMITED REGISTERED OFFICE: ABBEY ROAD; WHITLEY, COVENTRY, CV3 4LF, UK REGISTERED ENGLAND AND WALES COMPANY NO : 1672070 2

JR In Section 3 of the Notice it states thatthe "team from Jaguar / Landrover were preparinga technical report to assist the police but this was not progressed due tot death: JLR supportedthe Police requestfordata retrievaland JLR representatives extracted the data from the Vehicle on Znd May 2023 with officers from Devon and Cornwall Police_ The extracted data was decoded and then transferred to Devon and Cornwall Police on 19th May 2023. JLR was informed by Devonand Cornwall Police , via email on the same day,that in relation to the Vehicle: 'This data willno longer be required for a criminal prosecution asvery sadly the driver of the ipace has died from @ suspected heart attack JLR confirms this is the only requestfor support receivedin respect ofthis matterand noreport was requested JLRat all times fully supported Devon and Cornwall Police request in line with JLR's standard practices JLRis a responsible and ethicalmanufacturer considers the safetyofour products to be thehighest priority. Where legally permitted or authorised by the vehicle owner, ay allegation of a reported safety concern is investigated thoroughly: Report to prevent future deaths The following concerns are raised in the Notice (reproduced below for ease of reference): "During the course ofthe inquestthe evidence revealed matters giving rise to concern. In my opinion there is a risk that future deathscouldoccur unless action is taken: In the circumstances it is my statutoryduty to report to you: The MATTERS OF CONCERN are as follows_ (1) Although itis accepted thatthis death was accidental, duringtheinquestthefollowing information came to light as a result of the investigating police officer giving evidence: (2) There were a number of errors that were made by the driver which causedor contributedto the death These were Wrongly placing the car in drive instead of reverse Failing to look down at the camera and pressing the button to move forward by touch alone Failing to realise that the reversing warning sound which was saidto be very difficultto hear inside the car was not engaged Driving forward and continuing to do so for 8-10seconds after the accelerator was pressed Failing to press the brake at any time: (3 ) However, these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessaryto the car into drive _ reverse other than pressing a button: In the police officer' $ opinion if there had also been a lever or somethingsimilar present in the vehicle that needed to be engaged before a button was pressed this may havealerted [REDACTED] to the factthat he had pushed the incorrect button on the 3 button console. JLR took the following steps in response to the concerns raised in the Report JLR Abbey Road, Whitley, Coventry, CV3 4LF T,44 (012476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER UMITED REGISTERED OFFICE : ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF , REGIS TERED ENGLAND AND WALES COMPANY NO: 1672070 and put=

JR Reviewed the Report and considered assistance given to Devon and Cornwall Police Reviewed and considered all the information that is available in respect of the Vehicle in question (VIN Considered current legal requirements and safety standards applicable to the vehicle in question and this make and modelof vehicle in general: Considered the approach taken by othervehicle manufacturers in respectof the location and operation of the gear transmission control unit; Outcome of steps Section 5 paragraphs 2and 3 of the Notice states: "errors that were made by the driver which caused or contributedto the death Failingto realisethat the reversing warning sound which was said to be very difficult to inside the car was not engaged" "However, these errors occurred as @ result of there no intermediary step within the Jaguar ipace being necessary to the car into drive_ reverse other than pressinga button. In the police officer' s opinion ifthere had also been a lever or something similar presentin the vehiclethatneeded to be engaged before a button was pressed this may have alerted Mr Thompson to thefact that he had pushed the incorrect button on the 3 button console JLR confirms That the Vehicle Certification Agency are an Executive Agencyofthe Departmentfor Transportandexist to improve vehicle safetyand environmental protection by providingrobusttestingand certification tointernationall re cognised standards_ The gear transmission control unit is assessed for location and use as part of the vehicle certification process_ The Jaguar |-Pace is certified and meets all applicable United Nations Economic Commission for Europe (UN-ECE) regulated requirements_ Inaddition, the Jaguar |-Pace has achieved the highestsafety rating of 5 stars from the European New Car Assessment Programme (Euro NCAP) In reference to the type of geartransmission control unit used in the Jaguar |-Pace,other manufacturers use asimilar type of gear selector across many marques and models including, but not limited to Honda Motor Company Ltd; General Motors Company; Hyundai Motor Group; Ford Motor Company; Tesla Inc; Stellantis NV; Renault SA; Lotus Group Holdings Limited; McLaren Group Limited and Aston Martin Lagonda Global Holdings plc: A photo of the Jaguar |-Pace gear transmission control unit is provided below for ease of reference. JLR Abbey Road, Whitley, Coventry; CV3 4LF T.44 (012476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER UMITED REGISTERED OFFICE: ABBEY ROAD; WHITLEY, COVENTRY; CV3 4UF , REGISTERED ENGLAND AND WALES COMPANY NO : 1672070 hear being put fully

IR Figure 1- Photo of Jaguar |-Pace gear transmission control unit with reverse selected This gear transmission control unit is located in the centre console and measures 14.405 cm. Figure 2 - Computer Aided Design (CAD) image of Jaguar |-Pace gear transmission control unit with measurements Each button in the gear transmission control unit is clearly labelled, using the same labelling as any other automatic vehicle. As shown,the Reverse ("R")and Drive ("D") gear selector buttonsare not next to one another The distance JLR Abbey Road, Whitley; Coventry; CV3 4LF T. 44 (012476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED REGISTERED OFFICE; AbbEY ROAD; WHITLEY, COVENTRY, CV3 4LF , Uk REGISTERED IN ENGLAND AND WALES COMPANY NO : 1672070

JR betweenthe centre ofthe D R selectorsis 6.408 cm, with the button to select Neutral ("N") located between the Dand R gear selector buttons: The Jaguar |-Pace has surface differentiation on the Rand Park ("P") gear selectorbuttonsin order to assist drivers in selecting the relevantgear: For ease of reference,the R gear selector button has a raised tactile cue to distinguish R from the otherbutton selectors. This is in addition to the othervisual and auditory alerts, including the selectedgear button illuminating (as per UN-ECE Regulation121-Uniform provisions concerningthe approval of vehicles with regard to the location and identification of hand controls, tell-tales and indicators) . speedthreshold,in orderto be able tochange between'Drive' and 'Reverse' driving modes,is 7.7kph. Ifthe driver attempts to change between 'Drive' and 'Reverse' above this speed there willbe novehicle response i.e.no change in gear selected. A visual indication on the instrument cluster to indicate the gear selected, i.e. R showing on the instrument cluster when reverse gear is selected, is also provided to the driver. 0 Figure 3 - Image of the instrument cluster 0 with Park selected taken on 2nd 2023 during the vehicle inspection Also, when R is engaged, the rear facing image ad 360 degree surround view appears on the infotainment touchscreen (as shown below) which is clearly visible on the centre console above the gear transmission control unit: The infotainment touchscreen is a 10.25 inch LCD display with a resolution of 1920x720 and an aspect ratio of 8.3. JLR Abbev Road, Whitley, Coventry, CV3 4LF T. 44 (012476 303 080 JAGUARLANDROVER.COM JAGUAR LAND ROVER LIMITED REGISTERED OFFICE: ABBEY ROAD; WHITLEY, COvENTRY, CV3 ALF, UK REGISTERED ENGLAND AND WALES cOMPANY NO ; 1672070 and The May

JR ULan Figure 4 - Image of the infotainment touchscreen of taken on 2nd May 2023 during the vehicle inspection with reverse selected There is an Acoustic Vehicle Alert System (AVAS) which is designed to warn pedestrians, near to the Vehicle, of the Vehicle moving in reverse. This sound can be heard within the Vehicle_ minimum requirementforthe AVASis47dBs. In the Jaguar I-Pace the sound is designedto be in excess of 47dBs, exceeding the regulatory requirements and can be heard within the passenger cabin. As stated in the Notice Ifailed to engage the reverse gear selector button. Had Iselected the reverse gear selector button: The visual indicator in the instrument cluster would have displayed 'R'; The rear camera would have engaged on the 10.25 inch LCD infotainment touchscreen; The R gear selector button would have illuminated; and The auditory warning would have sounded_ The visual indicator on the instrument cluster is in the clear line of sight of the driver: The visual change on the infotainmenttouchscreenis a clear and obvious indication that youhave selected reverse, theauditory warning can be heard_ However, none ofthesefeatures would have been engaged orshowing Rat the time ofthe incident; as reverse had not been selected. The D gear selector would have been illuminated and the visual indicator in the instrument cluster would have displayed "D" Gear selection in the Jaguar |-Pace utilises all of the pertinent human senses; touch, sight and hearing: JLR has reviewed the data extracted from the Vehicle in the 10 seconds prior to the collision of the Jaguar |-Pace with the VW van: This data shows: The Vehicle did not come to a complete halt at any point; There was no brake pressure a5 a result of driver input; JLR Abbev Road, Whitley, Coventry; Cv3 4LF T. 44 (012476 303 080 JAGUARLANDROVER.COM LAND ROVER LIMITED REGISTERED OFFICE: ABBEY ROAD, WHITLEY, COVENTRY, CV3 4LF; REGISTERED ENGLAND AND WALES CoMPANY NO : 1672070 JJAGUAR The and

JR In the 5 seconds prior to the collision, the accelerator pedal was depressed at all times; and Atthe of collision, the accelerator pedal was depressed to 81%_ When observingthe driver' srequests madeto the vehicle,the acceleratorhad been depressed to 81% throttle where situationally the brake would normally be pressedto reduce the speed tozero (noting the vehicle accelerated slightly to mount the kerb) JLR would not expect any driver to command 81% throttle for a reverse manoeuvre. In the circumstances of the manoeuvring undertaken by the driver, you likely see a left steer adjustment just prior to reversal,in orderto straightenthe vehicle. Without making this left steeradjustment; the driverwould travel exactly on the path travelled in the forward direction but in reverse The data does not show this left steering adjustment; which would normally be made during manoeuvring, in order to straighten the vehicle_ Further, the Jaguar |-Pace IGuide (Owners manual) for the Vehicle states, in the section titled "Driving An Electric Vehicle IGuide Online [OHB]" , "Caution: To maintain control of the vehicle, it is recommended to press the brake pedal during each drive selection_ We thank the Coroner for the time taken to prepare the Notice and for permitting JLR to review the information provided Upon review ofall information and evidencein the case, including the data extracted from the Vehicle and independent vehicle safety testing, it is clear that the current design of the Jaguar |-Pace gear transmission control unit and alert strategy meet all legal requirements for vehicle safety and that no changes are required . JLR will continue to investigate issues of a safety related nature should thev arise, as required under the General Product Safety Regulations, will liaise as necessary with the Driver and Vehicle Standards Agency.
Report Sections
Investigation and Inquest
On 27th February 2023 I commenced an investigation into the death of Alfie Tollett age 7 . The investigation concluded at the end of the inquest on 16th August 2024 . The conclusion of the inquest was accident . The circumstances of the death were that on 19th February 2023 the Tollett family attended Plymstock Albion Rugby Football club to watch their eldest son play in a friendly training match against Exmouth RFC. The weather was dry and bright with clear blue skies. The club car park was full and club parking attendants were turning cars away. Alfie’s father parked his Kia Niro with all four wheels on the pavement that runs adjacent to the club car park on Wembury Road. Behind the Kia a white VW Transporter van was parked, unattended, with it’s nearside wheels on the pavement and it’s offside wheels on the road. Mr and Mrs Tollett went onto the pitches with Alfie and his little brother. Alfie was playing with his football and some other children at the side of the pitches. The rugby match lasted about an hour, once finished Mr Tollett and his two older sons returned to their car for the boys to change their shoes before they went into the clubhouse. Alfie went to the boot of the Kia to change his boots whilst Mr Tollett crouched on the pavement to untie his eldest son’s boots. Around 11:10 am and his wife were attending the rugby club to watch their son play in a match. was driving his wife’s Jaguar ipace electric vehicle registration number WF71LCL and his wife was in the front passenger seat. There was a space on the road between the white VW van parked unattended behind Mr Tollett’s Kia and a silver VW van parked further back from the white van. slowly pulled onto the pavement so his nearside wheels were on the pavement and his offside wheels were on the road. He used his left hand to select the reverse button to straighten the vehicle up. did not look down at the buttons on the centre consule and relied on feel to select reverse. He looked to his left in preparation to reverse and pressed the accelerator. The Jaguar moved forwards, as reverse had not been selected, failed to notice that the reversing warning alarm had not engaged and collided with the rear of the white VW van causing damage. did not brake and continued to accelerate pushing the white VW van forwards trapping Alfie between the VW van and his father’s Kia. Mr Tollett immediately got into his car and moved it forward to release Alfie who fell to the ground. He then went to Alfie’s aid but sadly Alfie died shortly afterwards with the cause of death being given as blunt force traumatic chest injuries . There has been no prosecution of the driver as he died of natural causes shortly after this incident . A team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due to Mr Thompson’s death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.