Investigation and inquest
On 7th January 2019, I commenced an investigation into the death of David Edwin BLINMAN. The investigation concluded at the end of the inquest. The conclusion of the inquest was Accidental Death.
Circumstances of the death
These were recorded as :-
On the afternoon of 28.12.18, David BLINMAN was walking home, via Railway Terrace. Whilst on Railway Terrace, he has either been struck by a reversing articulated lorry, or fallen into its path, proximate to this manoeuvre. This has led to him being crushed by the rear wheels of the tractor unit. His death was declared at scene by the attending emergency services. The incident occurred at a time when he was located within the vehicle's blind spot. Mitigating measures to reduce the risk of collisions with pedestrians were not actioned at the time of the incident. They, and the associated/applicable risk assessment were, in any event, in conflict with Rule 202 Highway Code, as the driver could not have seen clearly whilst reversing, and this likely contributed to his death.
The Inquest focused, inter alia, upon:-
a. The events immediately leading to, and of the collision on 28.12.18
b. The adequacy of the 2015, 2017 and 2019 Delivery Point Risk Assessments (DPRA), and their causal significance to the collision, if any.
c. Categorisation by the Risk Assessors completing the above of the types of vehicles to be employed to undertake deliveries to the Blandy Terrace NISA store, and the causal significance to the collision, if any.
Coroner’s concerns
(1) DPRA’s do not mandate discussion with and documenting of, by the Risk Assessor, the views and experiences of the store owner/operator, nor of the drivers regularly delivering to the store, in relation to any particular hazards, or concerns. The Risk Assessor may not, therefore, be sufficiently informed of material which might assist him, or her in completing an adequate risk assessment.
(2) The mitigating/control measures set out in the 2015, 2017 and 2019 DPRA’s do not adequately address the risks of vehicles colliding with pedestrians, in circumstances where the latter are located within vehicle blind spots. The measures, I understood from the evidence of the 2017 and 2019 Assessor, remain unchanged, and I believe, may well extend to all such DPRA’s, and not limited to the Blandy Terrace delivery location.
(3) 360 degree checks cannot be undertaken by a driver, whilst in the process of conducting a reversing manoeuvre, unless mitigating measures such as reversing cameras or a banksman are deployed
(4) Risk Assessors should have regard to current applicable driving guidelines, such as here, Rule 202 of The Highway Code when assessing risk and completing the DPRA