Alfie Tollett: Prevention of Future Deaths Report
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Date of report: 27/08/2024
Ref: 2024-0471
Deceased name: Alfie Tollett
Coroners name: Deborah Archer
Coroners Area: Devon, Plymouth and Torbay
Category: Child Death (from 2015)
This report is being sent to: Jaguar Land Rover
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED], CEO of Jaguar Land Rover | |
| 1 | CORONER I am Deborah Archer, Assistant coroner, for the Coroner area of The County of Devon , Plymouth and Torbay . |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 27th February 2023 I commenced an investigation into the death of Alfie Tollett age 7 . The investigation concluded at the end of the inquest on 16th August 2024 . The conclusion of the inquest was accident . The circumstances of the death were that on 19th February 2023 the Tollett family attended Plymstock Albion Rugby Football club to watch their eldest son play in a friendly training match against Exmouth RFC. The weather was dry and bright with clear blue skies. The club car park was full and club parking attendants were turning cars away. Alfie’s father parked his Kia Niro with all four wheels on the pavement that runs adjacent to the club car park on Wembury Road. Behind the Kia a white VW Transporter van was parked, unattended, with it’s nearside wheels on the pavement and it’s offside wheels on the road. Mr and Mrs Tollett went onto the pitches with Alfie and his little brother. Alfie was playing with his football and some other children at the side of the pitches. The rugby match lasted about an hour, once finished Mr Tollett and his two older sons returned to their car for the boys to change their shoes before they went into the clubhouse. Alfie went to the boot of the Kia to change his boots whilst Mr Tollett crouched on the pavement to untie his eldest son’s boots. Around 11:10 am [REDACTED] and his wife were attending the rugby club to watch their son play in a match. [REDACTED] was driving his wife’s Jaguar ipace electric vehicle registration number [REDACTED] and his wife was in the front passenger seat. There was a space on the road between the white VW van parked unattended behind Mr Tollett’s Kia and a silver VW van parked further back from the white van. [REDACTED] slowly pulled onto the pavement so his nearside wheels were on the pavement and his offside wheels were on the road. He used his left hand to select the reverse button to straighten the vehicle up. [REDACTED] did not look down at the buttons on the centre consule and relied on feel to select reverse. He looked to his left in preparation to reverse and pressed the accelerator. The Jaguar moved forwards, as reverse had not been selected, failed to notice that the reversing warning alarm had not engaged and collided with the rear of the white VW van causing damage. [REDACTED] did not brake and continued to accelerate pushing the white VW van forwards trapping Alfie between the VW van and his father’s Kia. Mr Tollett immediately got into his car and moved it forward to release Alfie who fell to the ground. He then went to Alfie’s aid but sadly Alfie died shortly afterwards with the cause of death being given as blunt force traumatic chest injuries . There has been no prosecution of the driver [REDACTED] as he died of natural causes shortly after this incident . A team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due to [REDACTED]’s death. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Although it is accepted that this death was accidental , during the inquest the following information came to light as a result of the investigating police officer giving evidence : 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 . 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 [REDACTED] to the fact that he had pushed the incorrect button on the 3 button console . |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd October 2024 . I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – The Tollett family. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | 27th August 2024 Deborah Archer |