Mollie Matilda Gifford · Prevention of Future Deaths report

On 19/04/2018 I commenced an investigation into the death of Mollie Matilda Gifford. The investigation concluded at the end of an inquest on 29th September 2020. The conclusion of the inquest was: ‘Died from unknown causes after being admitted to hospital with trauma caused during a road traffic collision.’

On 16 March 2018 Mollie was waiting at a traffic light controlled pedestrian crossing on Bromford Lane. A large goods vehicle, travelling towards Erdington, approached from the nearby junction with Washwood Heath Road and came to a halt 4 meters beyond the stop line. The cab had standard class 5 and 6 mirrors to assist the driver with visibility around the cab whilst stationary. It is unknown how close Mollie was to the cab as she crossed the road, but the closer she was the less visible she would have been to the driver. Mollie was walking slowly and was in front of the cab when the lights changed to green. The driver was unaware of Mollie and drove into her as he pulled away at slow speed. Mollie was admitted to Queen Elizabeth Hospital. She had suffered significant rib fractures, including a flail segment, and an associated haemothorax. She required a total right arm amputation following severe comminuted displaced fractures to her arm and hand. She had a number of complications including intermittent atrial fibrillation, breathing difficulties, a blood clot in her remaining left arm, and she suffered a small stroke. By 26 March there was some improvement in her condition, she was moving both lower limbs and remaining upper limb, and was alert and co-operative. On 28 March she was transferred to a general ward. However, she became symptomatic of a chest infection and deteriorated, dying at 9.50pm on 29 March. A standard post-mortem was performed and offered a cause of death relating to the trauma caused by the collision. There was no examination of the brain and no histology of the lungs. Two forensic pathologists conducted a paper review and disagreed with the stated cause of death. Whilst they felt the chest was the most likely cause of death, they could not say so with certainty. Therefore, the cause of death and role of the collision remains unknown.

The opinion of the forensic pathologists who conducted a paper review was that the medical cause of was ‘unascertained’.

I heard evidence from ████████ a forensic collision investigator of 15 years’ experience. Mr ████████ previously served for 23 years as a police officer involved in road traffic investigation and reconstruction – for the last 5 years he was in charge of a police collision investigation unit. Mr ████████ explained that the lorry cab was fitted with standard class 5 and 6 mirrors. He estimated in his career he had been involved in around 150 collisions between lorries and other road users and pedestrians where the class 5 and 6 mirrors did not provide the cab driver with adequate vision. The mirrors are convex and therefore even when clean provide a distorted view, but as they are prone to collect road dirt and spray, the distortion is easily amplified, making it difficult for cab drivers to see movement and colour. Some cab drivers will have a false sense of security about the ability of class 5 and 6 mirrors to provide a comprehensive view of other road users and pedestrians around the cab when stationary. Mr ████████ went on to explain that camera units are available on the market to stream live footage of around the cab to the driver on a screen. Camera units offer a clearer view, are not subject to the same distortion as class 5 and 6 mirrors and it is easier to pick out movement and different colours.

My ongoing concern is that standard class 5 and 6 mirrors create an avoidable risk cab drivers will not see other road users and pedestrians in close proximity to the cab when stationary.