Jon-Paul Prigent: Prevention of Future Deaths Report
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Date of report: 26/11/2024
Ref: 2024-0648
Deceased name: Jon-Paul Prigent
Coroners name: Peter Nieto
Coroners Area: Derby and Derbyshire
Category: Road (Highways Safety) related deaths
This report is being sent to: Department for Transport | Driving Standards Agency | The National Farmers Union | The Agricultural Engineers Association | The British Agricultural and Garden Machinery Association | The Health and Safety Executive
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: – 1. The Secretary of State for Transport 2. Driving Standards Agency (DVSA) 3. The National Farmers Union 4. The Agricultural Engineers Association 5. The British Agricultural and Garden Machinery Association 6. The Health and Safety Executive | |
| 1 | CORONER I am Peter Nieto, senior coroner for the coroner area of Derby and Derbyshire. |
| 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 31 July 2020 I commenced an investigation into the death of Mr Jon-Paul PRIGENT aged 47. The investigation concluded at the end of the inquest on 15 November 2024. The conclusion of the inquest was that: – Jon’s death was due to the decoupling of a laden trailer from its towing tractor. It is unlikely that his death would have occurred if the hitch and coupling components had been checked to a reasonable standard. |
| 4 | CIRCUMSTANCES OF THE DEATH Jon died on 30 July 2020 at Station Lane Old Whittington near Chesterfield, due to a trailer containing soil overturning on to the car he was in. Jon was sitting in the passenger seat preparing to give a driving lesson to his daughter. The trailer had decoupled from the tractor it was hitched to, and the trailer descended down the hill hitting a wall which caused it to overturn. The weight of the trailer put Jon into a compressed position and led to asphyxiation. The tractor and trailer belonged to and was used by a skip hire company. On 30 July they were being used to transport soil from the business premises and yard to the family home for use on land surrounding the property. The journey was along Station Lane, a public highway. The trailer decoupled from the tractor as the tractor went over a speed bump. That section of Station Lane is also on a hill. On the evidence the decoupling probably occurred due to a combination of factors: – – Wear of the coupling components: the towing hook, the hitch ring was warm to below its minimum thickness, and there was a gap between the location of the tip of the towing hook and the keeper plate. – The trailer was overloaded. It was manufactured for a maximum load of ten tonnes but the soil it was loaded with weighed thirteen point eight tonnes. – The soil was unevenly distributed and weighted more to the rear of the trailer adversely affecting the trailer’s centre of gravity. – As the hitch coupling passed over the speed bump a bigger gap opened up for the hitch ring to pass between the tow hook and keeper plate. – On inspection after the incident it was noted that the tip of the tow hook was missing. Whether it had been missing before the decoupling or was sheared-off during the decoupling cannot be established. – The owner and user of the tractor and trailer was required to check their roadworthiness including the hitch and coupling components before each day of use. It is unlikely that a check that day, or recent checks, had been adequate because had those checks been good enough, the degree of component wear would have been noted, and appropriate corrective measures should have been taken. Independent professional vehicle testing is not legally required for tractors and trailers used for agricultural purposes. The driver of the tractor stated that had he seen the degree of wear on the components he would not have taken the tractor trailer on to the road on 30 July. – The tractor and trailer did not have safety features to prevent decoupling because legislation does not require these for tractors which are driven at below twenty-five miles per hour. |
| 5 | CORONER’S CONCERNS 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: – 1. Tractors and trailers driven on roads for ‘agricultural purposes’ are not subject to periodic independent vehicle testing. This places the responsibility for checking roadworthiness on the user which is clearly dependent on the diligence and competence of the user. It is therefore highly likely that some tractors and trailers are being driven on roads for ‘agricultural purposes’ in unroadworthy and unsafe condition, as was clear in Mr Prigent’s inquest. 2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling (e.g. a safety chain, or dual safe braking system). Therefore, if decoupling occurs there is nothing to prevent independent and uncontrolled travel of the trailer. 3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling. 4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another. 5. At inquest I heard expert evidence on the above points, and that other nations, particularly in the European Union, have introduced comparatively robust legislation regarding testing and safety measures/fittings. 6. At inquest I heard evidence that the fitting of safety features to prevent decoupling is relatively low cost and that there have been previous voluntary schemes to encourage and incentivise these measures. |
| 6 | ACTION SHOULD BE TAKEN 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. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 21, 2025. 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:- · [REDACTED] · [REDACTED] · [REDACTED] · [REDACTED] I have also sent it to: – · Derbyshire police road traffic team, and · The National Police Chiefs’ Council lead for Roads Policing, Chief Constable [REDACTED] of Sussex Police, who may find it useful or of interest. 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. |
| 9 | Dated: 26 November 2024 Peter Nieto |