19 May 2026 Patricia Hazell · Prevention of Future Deaths report Oxfordshire
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Concerns raised 2
Lack of operator ability to mitigate identified residual risks through design or engineering controls View source Dependence on passenger warnings and checks for preventing falls from wheelchair access doors View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Patricia Hazell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Hazell fell from a coach at Broadway Rail Station when a wheelchair access door was opened from outside without warning or checks. She sustained serious injuries, reduced mobility and subsequently developed a fatal chest infection. The principal concerns were the design and operation of wheelchair access doors, reliance on warnings and checks that may be ineffective, and the potential for similar incidents involving serious injury or death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of operator ability to mitigate identified residual risks through design or engineering controls
Wider context from the report “• 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.
” Source location Patricia Hazell · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Dependence on passenger warnings and checks for preventing falls from wheelchair access doors
Wider context from the report “• 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.
” Source location Patricia Hazell · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Department for Transport to support its review of technical standards and regulatory requirements for public service vehicles.
Verbatim wording from the response “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.” Source location Response from Driver and Vehicle Standards Agency
Open published response
31 Jul 2017 Philip James Clayton · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to subject vehicles passing Individual Vehicle Approval to regular rigorous testing View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Philip James Clayton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip James Clayton was a passenger in a Zcar Mini that collided with another vehicle on 24 April 2016, and he died at the scene. The report raises concerns that sellers of high-powered kit-built vehicles are not required to provide a driving course, that such vehicles may not undergo rigorous regular testing after initial approval, and that current legislation permits people with a normal driving licence to drive modified or powerful vehicles regardless of experience.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to subject vehicles passing Individual Vehicle Approval to regular rigorous testing
Wider context from the report “The vehicle in question was a Z car which is a type of vehicle built using a kit and to which a high powered engine is fitted. There are a number of sellers of such vehicles in the country. None of these sellers have to provide any form of driving course in the use of such vehicles before they are sold. These vehicles once built have to undergo a rigorous test to comply with Driver & Vehicle Standards Agency under the Individual Vehicle Approval (IVA). This test is more a lot more involved than a normal MOT and checks things from the conformity of switches to the actual construction of the vehicle body and everything in between. Each item fitted to the vehicle is checked to ensure it conforms to the current legislation, if the vehicle passed the IVA then it is assigned a registration number more often than not a “Q” plate. However once this designation has been given it appears that the vehicles do not undergo such rigorous testing on a regular basis.
In addition, the driver of the vehicle was relatively inexperienced and had very limited experience of driving vehicles such as the one involved in this case. The current legislation allows a person to drive any modified or powerful vehicle once they have passed a normal driving test within the UK. This contrasts with the position where a person passes a motorcycle test. In that case then they are restricted by age to ride a reduced power machine for a period of time
” Source location Philip James Clayton · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ongoing regular IVA-standard testing is inappropriate because IVA applies only to unregistered vehicles and assesses new-vehicle design, not subsequent wear and tear.
Verbatim wording from the response “The purposes of MOT and Individual Vehicle Approval (IVA) testing differ greatly, and the Department does not think it would be appropriate to mandate ongoing, regular IVA-standard testing for specific types of vehicles in the way suggested. This is because IVA looks at the vehicle for its projected life and ensures that it can meet specified safety, security and environmental standards before it is used on the road. IVA only applies to unregistered vehicles; IT is a one off test that takes into account its design and construction, and takes no account of wear and tear (it’s treated as a new vehicle).” Source location 2017-0323-Response
Open published response
17 Apr 2014 Muriel Dawson · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 2
Lack of forward restraint or equivalent impact protection at passenger seats on narrow scheduled service buses View source Type-approval failing to give sufficient weight to the risk of death or serious injury View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Department for Transport
Raise the potential for additional passenger-protection design features with bus manufacturers through the SMMT technical group.
View source
Department for Transport
Raise the issue of additional passenger-protection design features at the next international technical group meeting.
View source
Department for Transport
Consider whether to propose amending minimum specifications for new vehicles, including type-approval requirements, to help prevent similar incidents.
View source
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AI-generated summary
Muriel Dawson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Muriel Dawson, aged 90, died shortly after being thrown forward from her unrestrained aisle seat when a public service bus braked suddenly. She suffered a complete fracture of the lumbar vertebrae and associated trauma. The principal concern was that the vehicle’s design and type-approval gave insufficient weight to the risk of death or serious injury to passengers, particularly because seats lacked restraints and a possible restraining feature was absent.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of forward restraint or equivalent impact protection at passenger seats on narrow scheduled service buses
Wider context from the report “(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 match 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.
” Source location Muriel Dawson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Type-approval failing to give sufficient weight to the risk of death or serious injury
Wider context from the report “(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 match 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.
” Source location Muriel Dawson · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the potential for additional passenger-protection design features with bus manufacturers through the SMMT technical group.
Verbatim wording from the response “The Coroner highlighted his concerns in Section 5 of the report. Within this I noted his suggestion that additional design features could have prevented Ms Dawson being thrown forward. Following the Coroner raising this matter with the Department, I 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.” Source location 2014-0173-Response-by-Department-for-Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the issue of additional passenger-protection design features at the next international technical group meeting.
Verbatim wording from the response “The Coroner highlighted his concerns in Section 5 of the report. Within this I noted his suggestion that additional design features could have prevented Ms Dawson being thrown forward. Following the Coroner raising this matter with the Department, I 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.” Source location 2014-0173-Response-by-Department-for-Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider whether to propose amending minimum specifications for new vehicles, including type-approval requirements, to help prevent similar incidents.
Verbatim wording from the response “The Coroner highlighted his concerns in Section 5 of the report. Within this I noted his suggestion that additional design features could have prevented Ms Dawson being thrown forward. Following the Coroner raising this matter with the Department, I 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.” Source location 2014-0173-Response-by-Department-for-Transport
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.