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Investigation and inquest
On 22 March 2017, Ms Kally Cheema (HM Area Coroner for Cumbria, now Senior Coroner for Cumbria) commenced an investigation into the death of Miss Rebecca Alice QUALT to whom I shall refer as Rebecca.
The investigation into Rebecca’s death concluded at the end of her inquest on 15 July 2019. Evidence had been heard over six days between 13 and 17 May inclusive and 31 May 2019.
The conclusion of Rebecca’s inquest was Road Traffic Collision.
The medical cause of death was 1(a) Severe Blunt Force Head Injury.
Circumstances of the death
On 15 April 2017, Rebecca was driving her car in the southbound carriageway of the A6 towards Kendal. ████████ was driving north in a Mercedes Sprinter van towing a trailer carrying a digger. Close to the entrance to Pink Quarry in Shap, the trailer detached from the van and continued on an onward trajectory. The trailer entered the southbound carriageway and collided with Rebecca’s car. The nose of the trailer entered the engine of Rebecca’s car. The boom of the digger entered the passenger cell of Rebecca’s car. Rebecca sustained a number of injuries as a consequence.
The inquest into Rebecca’s death was held over 6 days and heard evidence from 5 experts and other witnesses. My findings of fact included that:
1. The design of the tow hitch / coupling head was in accordance with legal requirements (i.e. Regulation 55 of the Economic Commission for Europe of the United Nations Uniform Provisions re Mechanical Coupling Components) and was not contributive to the cause of the incident.
2. There was no structural failure of the tow hitch.
3. There was a foreign object within the interface between the tow ball and tow hitch / coupling head.
4. The object in question could not be identified. It is likely to be metal or hard stone and between 1.5mm and 3mm thick.
5. How the object got into the interface cannot be determined.
6. The tow hitch could still be placed fully over the tow ball with the cup of the hitch encompassing the ball. However, the tow hitch was not fully engaged due to the presence of the foreign object.
7. There was no requirement on the operators to check within the tow hitch before starting the coupling process. There was no requirement on the operators to do anything other than a visual inspection of the tow hitch from a standing position. There was no national guidance to inspect the coupling from a close side on view.
8. Neither operator knew about the “Jockey Wheel Test”. The experts’ opinion was that this was not a 100% reliable check and that a visual check of the coupling should always be done.
9. The detachment has occurred at the point it did due to the unique topography of the A6.
10. Conservatively, the experts have over 100 years’ experience between them. They have never come across a foreign object in a hitch and had therefore not come across the cause of a trailer detachment to be a foreign object within the tow hitch.
11. The collision was therefore tragically unique due to the presence of a foreign object in the tow hitch (itself unique) and the unique topography of the A6 at the incident location.
12. My determination included that the trailer detached due to a foreign object present between the interface of the tow ball and towing hitch. The presence of the foreign object meant that the towing hitch was not fully engaged but may visually appear to be so.
The trailer coupling manufacturer (Indespension) and the trailer operator (T&K Gallagher Limited) have both taken steps to raise awareness of the possibility of a foreign object in the hitch and the importance of checks to ensure a coupling is fully engaged. Both have taken steps to disseminate that information to other operators but it is a concern that there may be operators who are unaware of the possibility of a foreign object in a coupler.
Coroner’s concerns
1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
Information checked against the published report and official responses