PFD report

Alfie Tollett · Prevention of Future Deaths report

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Issued 27 Aug 2024•Devon, Plymouth and Torbay

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published 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. Failure of the reversing warning sound to be sufficiently audible inside the car
    Part of recurring concern: Inadequate audible movement-warning systems on vehicles and mobile equipment
  2. Lack of an intermediary control step for selecting drive or reverse
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.1

  1. Action

    Consider other vehicle manufacturers’ approaches to gear transmission control-unit location and operation.

    Stated by Jaguar Land Rover LimitedStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The current gear transmission control unit and alert strategy meet all legal vehicle safety requirements, so the identified design risk does not require changes.

    Stated by Jaguar Land Rover LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Failure of the reversing warning sound to be sufficiently audible inside the car

Wider context from the report

“(2) There were a number of errors that were made by the driver which caused or contributed to the death . These were • Wrongly placing the car in drive instead of reverse • Failing to look down at the camera and pressing the button to move forward by touch alone • Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged • Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed • Failing to press the brake at any time . (3 ) However , these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer’s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted ████████ to the fact that he had pushed the incorrect button on the 3 button console . ”

Is this part of a recurring concern?

Yes — Inadequate audible movement-warning systems on vehicles and mobile equipment.

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

Lack of an intermediary control step for selecting drive or reverse

Wider context from the report

“(2) There were a number of errors that were made by the driver which caused or contributed to the death . These were • Wrongly placing the car in drive instead of reverse • Failing to look down at the camera and pressing the button to move forward by touch alone • Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged • Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed • Failing to press the brake at any time . (3 ) However , these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer’s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted ████████ to the fact that he had pushed the incorrect button on the 3 button console . ”

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

Consider other vehicle manufacturers’ approaches to gear transmission control-unit location and operation.

Verbatim wording from the response

“• Considered the approach taken by other vehicle manufacturers in respect of the location and operation of the gear transmission control unit.”

Source location

Response from Jaguar
Page 3 · response
Published 30 August 2024

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 current gear transmission control unit and alert strategy meet all legal vehicle safety requirements, so the identified design risk does not require changes.

Verbatim wording from the response

“We thank the Coroner for the time taken to prepare the Notice and for permitting JLR to review the information and evidence in the case, including the data extracted from the Vehicle and independent vehicle safety testing, it is clear that the current design of the Jaguar I-Pace gear transmission control unit and alert strategy meet all legal requirements for vehicle safety and that no changes are required.”

Source location

Response from Jaguar
Page 7 · response
Published 30 August 2024

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.3

  1. 1

    Review the Report and consider assistance provided to Devon and Cornwall Police.

    Stated by Jaguar Land Rover LimitedStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  2. 2

    Review and consider all available information concerning the vehicle involved.

    Stated by Jaguar Land Rover LimitedStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  3. 3

    Consider applicable legal requirements and safety standards for the vehicle and model generally.

    Stated by Jaguar Land Rover LimitedStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.

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 Report and consider assistance provided to Devon and Cornwall Police.

Verbatim wording from the response

“• Reviewed the Report and considered assistance given to Devon and Cornwall Police.”

Source location

Response from Jaguar
Page 3 · response
Published 30 August 2024

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 and consider all available information concerning the vehicle involved.

Verbatim wording from the response

“• Reviewed and considered all the information that is available in respect of the Vehicle in question (VIN ████████).”

Source location

Response from Jaguar
Page 3 · response
Published 30 August 2024

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

Consider applicable legal requirements and safety standards for the vehicle and model generally.

Verbatim wording from the response

“• Considered current legal requirements and safety standards applicable to the vehicle in question and this make and model of vehicle in general.”

Source location

Response from Jaguar
Page 3 · response
Published 30 August 2024

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
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Data last updated 7 September 2026