Harry Dunn
PFD Report
All Responded
Ref: 2024-0412
Hospital Death (Clinical Procedures and medical management) related deaths
Road (Highways Safety) related deaths
All 1 response received
· Deadline: 2 Oct 2024
Coroner's Concerns (AI summary)
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current training's coverage of wrong-way driving risks.
View full coroner's concerns
(1) In August 2019 there were two categories of US personnel based at RAF Croughton: those associated with the United States Air Force: the Military personnel and those associated with the United States State Department and their dependents: the Diplomatic personnel; (2) In terms of driver training provision there was a distinction between what was provided to the US Military and what was provided, or rather not provided, to Diplomatic personnel, The input provided to the US military personnel amounted to a driver briefing and the completion of a UK theory driving test. Nothing was provided to the diplomatic personnel, (3) had received no familiarisation or any other form of training between her arrival in the UK on 24 July 2019 and the accident o 27 August 2019_ Prior to the accident she had passed a 'throwback' arrow signalling to a driver if they happened to be overtaking to back to the left hand side_ However, had not yet familiarised herself with the UK Highway Code and neither had she been trained in the differences in and significance of road signs in the UK.
(4) Had she received appropriate training reminding her to keep to the left ad to help her to understand and interpret the UK road signs and markings it is possible the collision with Mr Dunn may not have occurred_ (5) Written evidence submitted by the US Embassy and read out at the inquest advised that since Mr Dunn's death driver training was now provided to all personnel, including family members, assigned to the US Mission wherever they are based in the UK. In addition at RAF Croughton further training was provided for newly arrived US Personnel which included a mandatory local conditions driver safety briefing focussed on the dangers of wrong way driving.
(6) However the evidence heard at the inquest as to the content of that briefing training was at odds with what had been described by the US Embassy: Specifically I was told that the driving training being provided did not specifically cover the risks of wrong way driving (7) That creates a concern for me as to a risk of future deaths_
(4) Had she received appropriate training reminding her to keep to the left ad to help her to understand and interpret the UK road signs and markings it is possible the collision with Mr Dunn may not have occurred_ (5) Written evidence submitted by the US Embassy and read out at the inquest advised that since Mr Dunn's death driver training was now provided to all personnel, including family members, assigned to the US Mission wherever they are based in the UK. In addition at RAF Croughton further training was provided for newly arrived US Personnel which included a mandatory local conditions driver safety briefing focussed on the dangers of wrong way driving.
(6) However the evidence heard at the inquest as to the content of that briefing training was at odds with what had been described by the US Embassy: Specifically I was told that the driving training being provided did not specifically cover the risks of wrong way driving (7) That creates a concern for me as to a risk of future deaths_
Responses
Action Taken
The government has sought assurances from US authorities regarding driver training for US Visiting Forces and diplomats, emphasizing driving on the left. The FCDO has also written to all diplomatic missions in the UK reminding them of road safety responsibilities. Ministers are considering further actions. (AI summary)
The government has sought assurances from US authorities regarding driver training for US Visiting Forces and diplomats, emphasizing driving on the left. The FCDO has also written to all diplomatic missions in the UK reminding them of road safety responsibilities. Ministers are considering further actions. (AI summary)
View full response
Dear Mrs Pember
REGULATION 28 REPORT, HARRY DUNN INQUEST
Thank you for your Regulation 28 report to Prevent Deaths issued after the inquest into the death of Harry Dunn, 10-13 June. His death was a tragedy and, as we approach the fifth anniversary of his death, our thoughts remain with his family, friends, and loved ones. We are committed to ensuring lessons are properly learnt.
On the specific issue which your report raised, the government has sought and received further assurances from the US authorities in the UK, both military and diplomatic, that driver training mandated for US Visiting Forces and diplomats, as well as their dependants, includes and will continue to include a focus on driving on the left, and the dangers of not doing so.
There is a continual need to focus on the issue of driver training and road safety awareness, especially as military forces and diplomats rotate through the UK. We are committed to continue work with the US to maintain our focus on this. We will be meeting the representatives of US Visiting Forces and the US Embassy in London again next month to do so.
The Foreign, Commonwealth and Development Office has also written to all diplomatic missions in the UK, reminding them of their responsibilities in respect of road safety awareness and driving standards in the UK. ,
Finally, ministers are considering what other actions, in addition to the actions taken over the last five years, might be required to ensure lessons have been learnt.
REGULATION 28 REPORT, HARRY DUNN INQUEST
Thank you for your Regulation 28 report to Prevent Deaths issued after the inquest into the death of Harry Dunn, 10-13 June. His death was a tragedy and, as we approach the fifth anniversary of his death, our thoughts remain with his family, friends, and loved ones. We are committed to ensuring lessons are properly learnt.
On the specific issue which your report raised, the government has sought and received further assurances from the US authorities in the UK, both military and diplomatic, that driver training mandated for US Visiting Forces and diplomats, as well as their dependants, includes and will continue to include a focus on driving on the left, and the dangers of not doing so.
There is a continual need to focus on the issue of driver training and road safety awareness, especially as military forces and diplomats rotate through the UK. We are committed to continue work with the US to maintain our focus on this. We will be meeting the representatives of US Visiting Forces and the US Embassy in London again next month to do so.
The Foreign, Commonwealth and Development Office has also written to all diplomatic missions in the UK, reminding them of their responsibilities in respect of road safety awareness and driving standards in the UK. ,
Finally, ministers are considering what other actions, in addition to the actions taken over the last five years, might be required to ensure lessons have been learnt.
Part of a Series
3 separate reports were issued from this inquest, each sent to different organisations.
-
2024-0411
Sent to: Department of Health and Social Care;All responded
-
2024-0413
Sent to: Department of Health and Social CareMedicines and Healthcare products Regulatory Agency1 of 2 responded
This report (2024-0412) is shown above.
Sent To
- Foreign, Commonwealth & Development Office
- Ministry of Defence
- Ministry of Defence Police
Response Status
Linked responses
1 of 3
56-Day Deadline
2 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
Report Sections
Investigation and Inquest
On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19. The investigation concluded at the end of the inquest on 13 June 2024. The conclusion of the inquest was: Road Traffic Collision
Circumstances of the Death
The circumstances of the death are as follows: On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by an employee of the US Government who had not long been in the UK and Whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Dunn; The cause of the collision was that on exiting RAF Croughton inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton. Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries_ He was attended to by an advanced medical team including Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
Staff training and development
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Staff training and development
Balancing vulnerability with professional curiosity
Southport Inquiry
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.