PFD report

Angela Stacey Carney · Prevention of Future Deaths report

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Issued 13 Jan 2025•West Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Lack of an independent secondary braking mechanism in some mobility scooters
  2. Potential safety hazards from use of older second-hand mobility scooters
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Continue liaising with the MHRA to establish whether further preventive measures are needed.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 15 January 2025.
  2. Action

    Continue monitoring reports and analysing emerging safety patterns concerning mobility-scooter braking mechanisms in freewheel mode.

    Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 15 January 2025.
  3. Action

    Collaborate with relevant stakeholders to disseminate the updated mobility-scooter guidance and emphasize freewheel-mode safety features.

    Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 15 January 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Responsibility for mobility scooter construction requirements rests with the MHRA, while the Department regulates their use in the built environment.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an independent secondary braking mechanism in some mobility scooters

Wider context from the report

“Although it is my understanding that more recently designed and manufactured mobility scooters are manufactured with a secondary braking system by way of a fitted hand brake mechanism, I am concerned that other manufacturers may be producing scooters without such an independent braking mechanism. I also have a concern that there may be many other older second hand models on the second hand market that are being used, which all combined has worrying safety implications for the rider’s and members of the public. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Potential safety hazards from use of older second-hand mobility scooters

Wider context from the report

“Although it is my understanding that more recently designed and manufactured mobility scooters are manufactured with a secondary braking system by way of a fitted hand brake mechanism, I am concerned that other manufacturers may be producing scooters without such an independent braking mechanism. I also have a concern that there may be many other older second hand models on the second hand market that are being used, which all combined has worrying safety implications for the rider’s and members of the public. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Continue liaising with the MHRA to establish whether further preventive measures are needed.

Verbatim wording from the response

“Officials in my Department will continue to liaise with the MHRA to establish whether anything further can be done to prevent such a tragic death happening in future; for example, by providing information to mobility scooter users highlighting the risks of operating in freewheel model and warning users about the absence of a secondary brake on older models of scooter.”

Source location

Response from Department for Transport
Page 2 · response
Published 15 January 2025

Open published response

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

Continue monitoring reports and analysing emerging safety patterns concerning mobility-scooter braking mechanisms in freewheel mode.

Verbatim wording from the response

“While we have received a relatively low number of reports potentially related to braking issues when in freewheel mode, we acknowledge the severity of harm that can occur if the device is not equipped with appropriate stopping mechanisms. We will therefore take the necessary steps to try and address the concerns raised. We will continue to monitor reports concerning”

Source location

Response from MHRA
Page 5 · response
Published 15 January 2025

Open published response

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

Collaborate with relevant stakeholders to disseminate the updated mobility-scooter guidance and emphasize freewheel-mode safety features.

Verbatim wording from the response

“4. We are aware of complexities associated with the use and purchase of mobility scooters, including the use of devices beyond their intended service life, purchase of second-hand devices from unauthorised retailers, and use of devices that are not safe. In addition to the existing guidance on the safe use of assistive technology devices¹, the MHRA is working on updating Medical devices: information for users and patients guidance to raise awareness on important considerations prior to purchasing a mobility scooter. The updated guidance will include key points for potential users to be aware of before purchasing their mobility scooter, including links to documents produced from other organisations to further strengthen the advice. The update is expected to be published by June 2025. We will inform you once the guidance is updated.”

Source location

Response from MHRA
Page 5 · response
Published 15 January 2025

Open published response

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

Review the current BS EN 12184:2022 provisions governing braking, emergency stopping, freewheel devices, alarms and speed-related safety in mobility scooters.

Verbatim wording from the response

“2. We have reviewed the current version of the standard BS EN 12184:2022 ‘Electrically powered wheelchairs, scooters and their chargers’. Requirements and test methods and the following provisions related to freewheel mode / device are included in the standard:”

Source location

Response from MHRA
Page 4 · response
Published 15 January 2025

Open published response

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

Sample registered powered-mobility-scooter manufacturers to evaluate whether UK-market devices have adequate safeguards against unintended movement in freewheel mode.

Verbatim wording from the response

“3. Using the data from our Registration Database, we have identified manufacturers who have registered with the MHRA as manufacturers of powered mobility scooters. We will sample a number of these manufacturers to evaluate the extent to which mobility scooters placed on the market in the UK are equipped with adequate safety features to mitigate the risk of unintended and uncontrolled movement while in freewheel mode. Following this initial review and based on its findings, we will undertake appropriate regulatory actions.”

Source location

Response from MHRA
Page 5 · response
Published 15 January 2025

Open published response

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

Update Medical devices: information for users and patients guidance with safety considerations for purchasing mobility scooters, including relevant external resources.

Verbatim wording from the response

“4. We are aware of complexities associated with the use and purchase of mobility scooters, including the use of devices beyond their intended service life, purchase of second-hand devices from unauthorised retailers, and use of devices that are not safe. In addition to the existing guidance on the safe use of assistive technology devices¹, the MHRA is working on updating Medical devices: information for users and patients guidance to raise awareness on important considerations prior to purchasing a mobility scooter. The updated guidance will include key points for potential users to be aware of before purchasing their mobility scooter, including links to documents produced from other organisations to further strengthen the advice. The update is expected to be published by June 2025. We will inform you once the guidance is updated.”

Source location

Response from MHRA
Page 5 · response
Published 15 January 2025

Open published response

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

Responsibility for mobility scooter construction requirements rests with the MHRA, while the Department regulates their use in the built environment.

Verbatim wording from the response

“The regulatory requirements for the construction of mobility scooters is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). The Department for Transport (DfT) has responsibility for the use of these vehicles in the built environment, and the relevant regulations are The Use of Invalid Carriages on Highways Regulations 1988.”

Source location

Response from Department for Transport
Page 1 · response
Published 15 January 2025

Open published response

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

The mobility scooter was compliant with the 1988 Regulations, including their braking-system requirements.

Verbatim wording from the response

“The DfT regulations specify the circumstances where mobility scooters may be used and contain provisions on the performance requirements these vehicles need to meet. Regulation 8 requires braking systems to be maintained, to be able to bring the mobility scooter to rest in all conditions of use, and capable of holding it stationary on a one in five gradient. The regulations permit a transmission brake which operates on the electric motor, and from the information available to us, the mobility scooter was compliant with the 1988 Regulations.”

Source location

Response from Department for Transport
Page 1 · response
Published 15 January 2025

Open published response

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

Existing standards comprehensively specify braking and freewheel safety requirements without requiring a particular independent hand-brake mechanism.

Verbatim wording from the response

“2. We have reviewed the current version of the standard BS EN 12184:2022 ‘Electrically powered wheelchairs, scooters and their chargers’. Requirements and test methods and the following provisions related to freewheel mode / device are included in the standard:”

Source location

Response from MHRA
Page 4 · response
Published 15 January 2025

Open published response

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

Regulating the sale of second-hand medical devices is outside the respondent’s remit.

Verbatim wording from the response

“While the MHRA does not regulate the sale of second-hand medical devices, where possible, we work with a range of stakeholders including patients and the public to work towards the promotion of safer medical devices and their safe use.”

Source location

Response from MHRA
Page 1 · response
Published 15 January 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Request and oversee the manufacturer’s review of internal serious-incident reportability processes, including identification of any implemented improvements.

    Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 15 January 2025.

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

Request and oversee the manufacturer’s review of internal serious-incident reportability processes, including identification of any implemented improvements.

Verbatim wording from the response

“1. We are working with the manufacturer of Sterling Sapphire mobility scooter to address the failure to report this serious incident to the MHRA in October 2024, in accordance with vigilance reporting requirements. To address this, the manufacturer has been requested to review their internal processes related to reportability and provide the MHRA with the outcomes of this review by 17 March 2025, indicating whether any improvements have been implemented.”

Source location

Response from MHRA
Page 4 · response
Published 15 January 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026