Brian Chapman: Prevention of future deaths report

Road (Highways Safety) related deaths

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Date of report: 24/01/2024

Ref: 2024-0164

Deceased name: Brian Chapman

Coroner name: Simon Milburn

Coroner Area: Cambridgeshire and Peterborough

Category: Road (Highways Safety) related deaths

This report is being sent to: Department for Transport

1    Department for Transport
I am Simon MILBURN, Area Coroner for the coroner area of Cambridgeshire and Peterborough
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.
On 14 July 2020 I commenced an investigation into the death of Brian William CHAPMAN aged 76. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that:   Medical cause of death – 1a Multiple traumatic injuries; Conclusion – Road Traffic Collision
Mr Chapman was a passenger seated on the upper deck of a bus travelling eastbound on the A47 at Wisbech St Mary on 26.06.18. At approximately 0728hrs the bus driver did not react to the presence of an articulated lorry which was undertaking a right hand turn from a haulage depot on the nearside of the carriageway onto the westbound carriageway of the A47. The bus collided at sped with the lorry trailer which was sat across the eastbound carriageway. Extensive damage was caused to both vehicles and sadly Mr Chapman suffered significant and unsurvivable traumatic injuries. His death was confirmed at the scene by a paramedic at 0826hrs.
During the course of the investigation my inquiries 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: (brief summary of matters of concern)  
One of the two vehicles involved in the collision was a double decker service bus travelling a scheduled route between Peterborough and Norwich, a distance of approximately 80 miles. The bus was not fitted with passenger seatbelts. I heard evidence that although since 01.10.01 seatbelts are required to be fitted in all new buses(this vehicle was on a ‘63’ plate’) there is an exemption where such vehicles are designed for urban use with standing passengers.

Whilst this particular route required the bus to travel from/to and stop off in 5-6 urban centres the majority of the journey took place on a major A route through rural areas. The speed of the bus at the point of collision was approximately 53mph. Both the bus driver and an upper deck passenger were killed in the collision.
Whilst there was no evidence that either death would have been prevented by the wearing of seatbelts a number of other passengers were injured in the collision.
I am concerned where buses are undertaking journeys such as this through predominantly rural locations and subject to the national speed limit without seatbelts being required there is an obvious risk of death to passengers if collisions occur, particularly at high speed.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by March 25, 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Family of [REDACTED]
Family of Mr Chapman
Legal Representatives for Brett Transport Legal Representatives for First Bus
Legal Representatives for [REDACTED]
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 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 by the Chief Coroner.
9Dated: 24/01/2024
Simon MILBURN Area Coroner for Cambridgeshire and Peterborough