Source · Prevention of Future Deaths

Patricia Hazell

Ref: 2026-0254 Date: 19 May 2026 Coroner: Nicholas Graham Area: Oxfordshire Responses identified: 1 / 1 View PDF

Concerns are raised about wheelchair access doors on coaches potentially opening from the exterior, with existing warnings to passengers inside not always effective. Operators lack ability to mitigate this design risk.

Date 19 May 2026

56-day deadline 11 Sep 2026 est.

Responses identified 1 of 1

Coroner's concerns

AI summary

View full coroner's concerns

• The design and operation of wheelchair access doors on coaches may permit the door to be opened from the exterior
• That risks of falling was dependant solely on giving warnings to passengers inside and checking whether a person is leaning against the door. Such warnings may not always be effective.
• Where operators have identified residual risk, they may have no ability to mitigate that risk through design or engineering controls, as responsibility for such matters lies with the vehicle approval and safety regime overseen by the DVSA.
• In those circumstances, there is a concern that similar incidents could recur involving disabled access doors on coaches, with the potential for serious injury or death.

For these reasons, I consider it appropriate to report this matter to the DVSA so that the safety aspects of disabled access doors on coaches may be reviewed in light of the circumstances of this death.

Responses

1 respondent

Driver and Vehicle Standards Agency Other

26 Jun 2026 PDF

Action Planned

The DVSA is working with the Department for Transport to review relevant technical standards and regulatory requirements for Public Service Vehicles. They will also ensure the concerns are reflected in best-practice guidance for operators and explore raising awareness through trade bodies. (AI summary)

View full response

Dear Mr Graham,

Thank you for your letter of 19 May concerning the inquest into the death of Patricia Hazell, which concluded on 19 May 2026, and the resulting regulation 28 report to prevent future deaths. We offer our sincere condolences to Ms Hazell’s family and friends.

The Driver and Vehicle Standards Agency (DVSA) recognises the seriousness of the concerns raised about access to service and emergency doors on Public Service Vehicles (PSV). Current regulations require service and emergency doors, including wheelchair access doors, to be capable of being opened from both inside and outside the vehicle when stationary. These requirements are intended to support safe access to, and evacuation from, vehicles in an emergency.

The regulations also allow devices that prevent doors from being opened while a vehicle is in motion. This provision is intended to protect passengers by reducing the risk of individuals falling from moving vehicles.

DVSA is working closely with the Department for Transport to support its review of the relevant technical standards and regulatory requirements for PSVs. DVSA will also ensure that the circumstances identified in the regulation 28 report are reflected in best-practice guidance for operators and will explore further opportunities to raise awareness through trade bodies. These actions are intended to help strengthen safety arrangements and reduce the likelihood of similar tragic incidents occurring in future.

I am content for a copy of this response to be shared with all interested parties.

Report sections

Investigation and inquest

On the 4 June 2025 I commenced an investigation into the death of Patricia Hazell, aged 82, following injuries sustained in a fall from a coach.

On the 18 May 2026 I held an Inquest with a Jury.

The medical cause of death was confirmed as 1a. Bilateral bronchopneumonia, caused by 2. Hypertensive heart disease, and rib and spinal fractures following a fall

The Jury determined how, when and where Mrs Hazell died, finding that: On the 9th April 2025, at Broadway Rail Station, Gloucestershire, Mrs Hazell fell from a coach, when the wheelchair access door she was leaning against was opened from the outside without warning or checks being undertaken.

The significant injuries Mrs Hazell sustained led to decreased mobility and a fatal chest infection which caused her death on the 25th May 2025 at the John Radcliffe Hospital, Oxford. Their Conclusion was Accident.

Circumstances of the death

The deceased was a passenger on a coach and was standing adjacent to the wheelchair access door. The door was opened from outside the vehicle without warning to those inside and without checks being undertaken as to whether any passenger was leaning against it.

As a result, the deceased fell from the coach and sustained serious injuries. Those injuries led to a reduction in her mobility. Subsequently, she developed a chest infection from which she died. Evidence was heard that the operator had undertaken a risk assessment relating to the risk of falling from the access door when the door was in use for boarding or alighting, but not in circumstances where the door was simply opened from the exterior while the vehicle was otherwise stationary.

Following the incident, the company took steps within its control, including issuing warnings and notifications to passengers when disembarking (although it was accepted that notifications given when disembarking may not always be heard or understood) and changing seating practices so that non disabled passengers were not seated adjacent to the access door. Evidence was also given that any design changes to the door mechanism or safeguards were matters for the DVSA.

Action should be taken

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

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Report details

Reference: 2026-0254
Date of report: 19 May 2026
Coroner: Nicholas Graham
Coroner area: Oxfordshire

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: 11 Sep 2026 (estimated).

Sent to

Driver and Vehicle Standards Agency

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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