Mustafa Nadeem: Prevention of future deaths report

Child Death (from 2015)Road (Highways Safety) related deaths

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Date of report: 11/07/2023

Ref: 2023-0237

Deceased name: Mustafa Nadeem

Coroner name: James Bennett

Coroner Area: Birmingham and Solihull

Category: Child Death (from 2015) | Road (Highways Safety) related deaths

This report is being sent to: Department For Transport, West Midlands Combined Authority, and Collaborative Mobility UK

The Rt Hon Mark Harper MP, Secretary of State for Transport – Department For Transport
[REDACTED] Mayor of the West Midlands, Chair – West Midlands Combined Authority
[REDACTED] Chief Executive – Collaborative Mobility UK.
I am James Bennett, Area Coroner for Birmingham and Solihull.
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 12 December 2022 I commenced an investigation into the death of MUSTAFA NADEEM. The investigation concluded at the end of the inquest.
On 6/12/22 Mustafa was riding an e-scooter to school on the pavement on the B4128, approaching the traffic island with Belchers Lane, Bordesley Green when at 7:58am he inadvertently collided with a pedestrian and fell into the path of a bus that was travelling at slow speed. He suffered fatal injuries and was confirmed deceased at the scene. The e-scooter was authorised for use in Birmingham as part of a national pilot scheme and users were required to have a valid motor-vehicle driving licence and be aged over 18. The e-scooter being used by Mustafa had been unlocked by a 14-year-old friend via an ‘app’ on his mobile phone.  

The medical cause of death was conformed at post-mortem examination: Multiple injuries.

The formal conclusion as to the death: Death was a consequence of a road traffic collision.
During the inquest the evidence revealed matters giving rise to concern. The

MATTERS OF CONCERN are as follows:
Hire e-scooters are only available as part of a national pilot scheme. The scheme is implemented locally. Guidance to the providers of hire e-scooters is currently limited to Department for Transport guidance. There is no regulatory body.
Hire e-scooters are legally classed as motor vehicles and require the user to have a driving licence. In this case it was also a licencing condition that users were aged 18+.
The deceased was using a hire e-scooter to travel to school despite having no driving licence and being aged 12. The account used to access the hire e-scooter belonged to a friend who had no driving licence, was aged 14, and was regularly using an under 16s bank account to pay for rides.
I heard evidence that Department for Transport guidance requires a driving licence, age and identity check when an account is created on a mobile device. However, users can easily transfer the account to another device and no further identity and age check is required. In this case the account was originally created on an adult’s mobile phone, but quickly and easily transferred to a child’s mobile phone and payment switched to an under 16s bank account. Department for Transport guidance did not require the e-scooter provider to undertake any age or identity checks at the point of transfer.
I heard evidence that the providers of hire e-scooters have no ability to detect if a child’s bank account is being used to pay for rides. In this case, had the provider been able to detect the use of a child’s bank account it would have alerted them to illegal use on the account and action could have been taken.
I heard evidence from the head teacher of the deceased’s school that from the outset of the hire e-scooter pilot scheme pupils riding e-scooters illegally was instantly problematic. Upon it being known the school would seize e-scooters pupils would simply abandon them at the end of the road. Despite education and the facts of this death being known, children from the same school and other schools continued to use hire e-scooters illegally.
I heard evidence that education is paramount to safe use of hire e-scooters and this requires a collaborative approach.
In my view the use of hire e-scooters is not analogous to the supply of other motor vehicles. During the evidence the point was made that the manufacturers of cars/motorbikes do not undertake any checks once the vehicle is with the customer. This can be contrasted to hire e- scooters being readily available, do not involve any face-to-face contact with a responsible adult at the point of unlocking, and are quickly accessed via mobile phone ‘apps’. Children are likely to have many ‘apps’ on their mobile phones and the legal significance of a motor vehicle ‘app’ is likely to be diluted and/or not appreciated at all.
In summary:
My principal concern is the evidence demonstrates the ease in which children can (illegally) use hire e-scooters.
My specific concerns are the evidence demonstrates current hire e-scooter precautions, and education/information, is not effective in preventing children from (illegally) using hire e-scooters.
In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
1.     The pilot scheme is run by the Department for Transport.

2.     The pilot scheme is implemented locally. In this case by The West Midlands Combined Authority who have confirmed the pilot scheme is about to re-commence in Birmingham.

3.     There is no regulatory body or association of e-scooter providers. However, I heard evidence that hire e-scooter providers liaise with Collaborative Mobility UK who are a national organisation for shared transport and work with national and regional authorities on the use of e-scooters.
In my opinion action should be taken to prevent future deaths and I believe you 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 5 September 2023. 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:
(1)  Mustafa Nadeem’s family.
(2) [REDACTED] , Chief Constable, West Midlands Police.
(3)  Voi Technology Ltd ([REDACTED], General Manager for the UK).
(4)  [REDACTED] (driver of the bus).
(5)  Saltley Academy ([REDACTED] Headteacher).
(6)  Washwood Heath Academy ( [REDACTED] Headteacher)
and to the Local Safeguarding Board as the deceased was under 18 years of age.

I am also under a duty to send the Chief Coroner a copy of your response.

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.
911 July 2023
James Bennett, Area Coroner, Birmingham and Solihull