Muriel Dawson

PFD Report Partially Responded Ref: 2014-0173
Date of Report 17 April 2014
Coroner Timothy Ratcliffe
Response Deadline est. 12 June 2014
Coroner's Concerns (AI summary)
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately consider the risk of death or serious injury.
View full coroner's concerns
(1) My findings were, as summarised in the narrative conclusion, that Muriel Dawson was travelling on an Optare “hopper” type scheduled service bus (narrow model) and the evidence to the Coroner’s court indicated that the profile of passengers on such a vehicle would overwhelmingly be elderly. The evidence given was to the effect that the design of the vehicle provides a compromise between safety and convenience as it allows for standing passengers, seated passengers and provision for a wheelchair. The design is such that the seat in which Mrs. Dawson was seated at the time of the incident has no form of restraint should there be a violent forward motion exerted on passengers, eg. by an emergency stop. The seat position (viewed from the front facing back) is on the right hand side and is in the third row. It is the aisle seat of the first double seats, the two rows in front being single seats on that side.

(2) It is understood that these vehicles are type-approved and the operator has not made modifications to them and thus the original design and approval of the vehicle is universally that which is in regular use. Seat belts are not required to be fitted to any seats.

(3) The evidence to the inquest was that this vehicle had to stop suddenly; the brakes were correctly applied, but there was nothing to prevent Mrs. Dawson being thrown forward and she lost her life as a result of hitting the front panel of the bus having slid the remaining length of the vehicle. Her death was due to the impact with the vehicle fracturing her spine.

(4) It appeared from evidence that, still consistent with convenience, disabled access and gangway width, a floor to ceiling pole with horizontal bar, or some similar restraining construction could have been applied to the area immediately in front of her seat.

(5) It is appreciated that the backs of seats, bars and similar elements of the interior of a vehicle can cause injury in the event of a sudden stop, but I considered, based on the evidence given, that some similar design feature of the vehicle as mentioned in (4) above could, and probably would, have prevented Mrs. Dawson being thrown forward for such distance and with such momentum as to cause her death.

(6) It appears from the evidence, albeit indirectly reported to the Coroner at the inquest, that other operators have expressed concerns with the current design, but feel there is nothing they can do in a type-approved vehicle. I am concerned that the type-approval has given insufficient weight to the risk of death or serious injury.
Responses
Department for Transport Central Government
12 Jun 2014
Action Planned
The Department for Transport will raise the coroner's concerns about bus seat design with bus manufacturers and at the next meeting of the International technical group to consider amending minimum specifications for new vehicles. (AI summary)
View full response
Dear Miss Plovie refer to your letter of 16 April following the inquest into the death of Ms Muriel Dawson. On conclusion of the inquest Her Majesty's Coroner made a finding that the design and location of the seat on which Dawson was sitting on the bus contributed to her fall and ultimately to her death: am replying as Head of International Vehicle Standards division which has responsibility for road vehicle safety standards was grateful for the information provided in the Coroner's Regulation 28 Report and have made further enquiries with the Driver and Vehicle Standards Agency (formerly the Vehicle & Operator Services Agency) , which is an Executive Agency of the Department for Transport with responsibility for bus certification and roadworthiness in Great Britain: The subject vehicle (Registration Number YJ6O KFR) was first registered in October 2010 and is certified to a maximum of 25 seated passengers, 16 standees and wheelchair user although these capacities would not apply simultaneously. To attain the maximum standing capacity all of the folding seats would need to be in the stowed position. In common with most buses currently operating in the UK, the vehicle on which Ms Dawson was travelling when she receivved fatal injuries was approved to national regulations. These regulations specify the general safety items of the vehicles and include, for example emergency exits, lighting, and additional features to make it easier for disabled people, including wheelchair users to gain access. Amongst other provisions_ set requirements for additional hand holds, minimum of 1 wheelchair space together with a minimum of four priority seats for the disabled and elderly passengers. These priority seats extra legroom and can be easily reached from the entrance of the vehicle_ It is also important to recognise that incidents involving buses and coaches are rare Travel by bus and coach is one of the safest modes of road transport in Great Britain, with the rate of killed and seriously injured passengers per mile travelled approximately one third that of passenger cars_ The Department is committed to improving safety for all bus passengers through the use of appropriate vehicle construction standards and ensuring the safe operation of vehicles. Vehicle manufacturers some flexibility to install additional design features that benefit passengers providing do not compromise the existing construction requirements City Ms carry her they have being have they

national regulations setting the minimum standards for new vehicles utilise a number of specifications that are harmonised with EU and wider international requirements. These standards are reviewed regularly by an International group of experts under the United Nations Economic Commission for Europe_ The Department for Transport is an active participant in this group. The Coroner highlighted his concerns in Section 5 of the report Within this noted his suggestion that additional design features could have prevented Ms Dawson being thrown forward. Following the Coroner raising this matter with the Department, intend to bring this to the attention of the bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT) technical group. My team will also raise the issue at the next meeting of the International technical group and consider whether it is appropriate to propose amending the minimum specifications for new vehicles (including those relating to the type approval) to help prevent this type of incident occurring in future am grateful for the Coroner raising this issue with the Department.
Sent To
  • Optare
  • Transport Research Laboratory
  • Vehicle Operator Services Agency
Response Status
Linked responses 1 of 3
56-Day Deadline 12 Jun 2014
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 6th November 2013 I commenced an investigation into the death of Muriel Dawson, aged 90 years. The investigation concluded at the end of the inquest on 11th April 2014. The conclusion of the inquest was a narrative verdict as follows:

“Muriel Dawson suffered an injury to her spine, fracturing her lumbar vertebrae L1/2, as the result of her being thrown forward from her seat in an Optare 25/28 seater public service vehicle travelling at under 20 miles per hour which braked suddenly to avoid the possibility of contact with a car preparing to enter into the roadway from a private drive. She had been seated in an aisle seat towards the front of the vehicle with nothing to restrain her forward movement. No seat belt was fitted to her seat. Other passengers in the bus were also thrown from their seats but did not suffer serious injury. The fracture of her vertebrae and associated trauma led to her death shortly after the incident”, the cause of death being 1(a) Complete fracture lumbar vertebra (L1/2) due to 1(b) Osteoporosis.
Circumstances of the Death
These are as shown in the narrative conclusion in Box 3 above.
Inquest Conclusion
“Muriel Dawson suffered an injury to her spine, fracturing her lumbar vertebrae L1/2, as the result of her being thrown forward from her seat in an Optare 25/28 seater public service vehicle travelling at under 20 miles per hour which braked suddenly to avoid the possibility of contact with a car preparing to enter into the roadway from a private drive. She had been seated in an aisle seat towards the front of the vehicle with nothing to restrain her forward movement. No seat belt was fitted to her seat. Other passengers in the bus were also thrown from their seats but did not suffer serious injury. The fracture of her vertebrae and associated trauma led to her death shortly after the incident”, the cause of death being 1(a) Complete fracture lumbar vertebra (L1/2) due to 1(b) Osteoporosis.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.