Source · Prevention of Future Deaths

Percy Gurton

Ref: 2014-0546 Date: 22 Dec 2014 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 1 / 1 View PDF

The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.

Date 22 Dec 2014
56-day deadline 15 Feb 2015
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
View full coroner's concerns
(1) The bus is so designed that there is no barrier at least in front of the front seat on the right hand side where Mr Gurton was sitting at the time.

Responses

1 respondent
First Essex Buses Other
13 Feb 2015 PDF
Action Planned

First Essex Buses is investigating with Optare the feasibility of retro-fitting containment measures onto the relevant bus and is engaging with other parties to explore the issue of containment for priority seats with the aim of adopting an industry-wide approach. They note this initiative is ongoing and any unilateral action would have piecemeal effect. (AI summary)

View full response
Dear Mrs Beasley-Murray Inquest into the Death of Mr P Gurton refer to your letter dated 22 December 2014 enclosing a Report to Prevent Future Deaths pursuant to regulation 28 of the Coroners (Investigations) Regulations 2013 ("the Report") . This Report was written following the conclusion of the inquest into the death of Percy William Gurton First Essex has offered our sincere condolences to Mr Gurton's family for their loss. We have also offered support to the driver of the bus in question: note there is no criticism whatsoever of the actions of the bus driver which has been of some comfort to him in this tragic event_ Your report records your opinion that action should be taken to prevent future deaths and asks that First Essex gives consideration to incorporating a barrier of some sort in front of the relevant seat. Essex Buses Limited cpt iiii Registered in England number 1961457 member Atoc 5 Westway: Chelmsford, Essex, CMI 3AR Frsi

First Westway Chelmsford Essex CM1 3AR Tel: Fax: Actions_taken to date The tragic accident involving Mr Gurton was investigated fully by First Essex at the time in accordance with its health and safety policies and procedures_ In addition, First Essex CO-operated with relevant authorities on their independent investigations including Essex Police_ Upon receipt of your letter dated 22 December 2014 and its report; we have since met with the manufacturer of the relevant bus involved in this incident; Optare, on 15 January 2015. First is investigating with Optare the feasibility of retro-fitting some form of containment onto this type of bus which may help to prevent future deaths in circumstances such as those which occurred involving Mr Gurton: In principle, a technical solution may include not only a barrier but other possibilities such as handpoles: However, the risks associated with such a solution need to be carefully evaluated, as there is a possibility that an unintended consequence of any adaptation may be to actually increase the incidence and severity of passenger injuries overall in the event of a collision or emergency braking: such fixtures to the interior therefore has to be considered carefully as it may introduce additional risk of harm to passengers rather than reduce it: Moreover, that response will subsequently also need to be assessed against and take into account specific regulatory and licensing requirements on construction, design and accessibility of public service vehicles and applicable industry and regulatory guidelines and proposals (see below): Iechnical_regulatory industry issues The bus in question is manufactured by Optare and is their "Solo" range It was registered in 2002 and is some 13 years old. First Essex currently operates 24 of this type of vehicle with the same seating configuration but there are many more in service throughout the UK with other bus operators (including other FirstGroup bus operators)_ The bus itself was purchased with the standard internal configuration at the time as designed by the manufacturer, and as built to the "Certificate of Initial Fitness" (COIF) standards and it complies with all legal requirements for operation. In the UIp First Ecsex Buses Limitcd cpt ii Member Registered in England number 1961457 member Atoc Regikea Westway; Chelmsfcrd, Essex, CMI 3AR fully Adding and from

First Westway Chelmsford Essex CMI 3AR Tel: Fax- first instance, issues of technical modification to buses should be referred to the relevant manufacturer by the bus operator and this is what First Essex has done. In addition, matters in relation to the construction, design and accessibility of buses are subject to a number of specific regulations and licence conditions_ proposed technical modifications must therefore also be assessed against regulatory and licensing requirements and developed with authorities to ensure continued legal compliance with current legislation and guidance. Quite often, the issue of containment is specific to priority seating areas and any change to the configuration could potentially affect accessibility Moreover, it has become clear that the issue that you have raised is not an isolated one and nor is it an issue specific to this type of bus or to First Essex The Department for Transport has flagged the issue of containment (primarily on older buses) around priority seating and wheelchairlbuggy spaces with industry and manufacturer representatives (including Confederation of Passenger Transport of which FirstGroup is a member). All parties are actively engaging on exploring the relevant issues with the aim of adopting an industry-wide approach. The engagement recognises that the issue of containment for priority seats is not unique to the Optare "Solo" bus type (First Essex itself operates number of different types of buses from multiple manufacturers as does every major bus operator in the UK) or to any particular bus operator. This initiative is active and ongoing so First Essex cannot as yet confirm what actions may result from this_ However, currently, it is anticipated that; a code of practice may potentially be developed which would apply to all relevant bus operators in the UK. Naturally, this aligned approach would much better address concerns of the type that you have raised_ Actions proposed to be_undertaken and_timetable Whilst First Essex is continuing discussions with Optare, the consideration of the outcome of those discussions must necessarily take into account existing regulatory and licensing requirements and any ongoing industry discussions on the same issues. unilateral action which any single bus operator may take would otherwise have piecemeal effect at best and may lead to unintended consequences or non-compliance with new industry or Department for Transport requirements. Ulp First Eszex Buses Limited cpt ii Member Registered in England number 1981457 member Atoc Reglea Westway; Chelmsford, Essex, CMI 3AR Any the Any

First Westway Chelmsford Essex CMI 3AR Tel: Fax At present;, the Department for Transport's engagement with stakeholders on this issue is ongoing: There is no fixed timetable in respect of concluding that engagement or the production of any outputs from it: However, should you wish, would be glad to keep you updated on developments from that:

Report sections

Investigation and inquest
On 12 August 2013 I commenced an investigation into the death of Percy William Gurton. The investigation concluded at the end of the inquest on 18 December 2014. The conclusion of the inquest was Accident The cause of death was 1a) bilateral pneumonia 1b) hypoxic brain injury and neck injuries
Circumstances of the death
Percy Gurton was a an elderly passenger on a bus which needed to make an emergency stop because a cyclist swerved in front of it. Mr Gurton was propelled forward off his seat and collided with the front of the inside of the bus. He sadly died from the injuries he sustained. There is no criticism whatsoever of the bus driver.
Action should be taken
Consideration should be given to incorporating a barrier of some sort in front of the relevant seat. 2

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Report details

Reference
2014-0546
Date of report
22 December 2014
Coroner
Caroline Beasley-Murray
Coroner area
Essex

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Feb 2015.

Sent to

First Essex Buses

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