Leonardo Machado (2): Prevention of future deaths report

1) Secretary of State for Work and Pensions 
2) Secretary of State for Business and Trade 
3) Secretary of State for Transport 
4) Secretary of State for Education 
5) Chief Executive of the Health and Safety Executive

I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset

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 the 19^th April 2023, an investigation was commenced into the death of Leonardo Cardoso Machado, born on the 13^th July 2005. 

The investigation concluded at the end of the Inquest on the 11^th September 2025. 

The Medical Cause of Death was:
1a Traumatic Head and Neck Injuries  

The conclusion of the Inquest as recorded by the jury empanelled to hear the Inquest was that Leonardo Cardoso Machado died at Lindsay Road near junction with St Aldhelm’s Rd, Poole, Dorset on 16th April 2023. 

On balance of probability the fact the Police attempted to effect a traffic stop at the County Gates Gyratory caused Leo to “make off” at high speed through the red traffic lights to continue to travel at speed along Lindsay Rd. 

The excessive speed of the motorbike driven by Leo was the causative factor in the collision causing Leo to lose control at the bend in the road and drive into the railings on Lindsay Rd.  

The cause of death was traumatic head and neck injuries caused by the road traffic collision.  

Leo was 17 years of age at the time of his death. Leo “rented” an “Uber Eats” delivery licence, though he was too young to obtain such a licence himself. As a result of the rented licence, Leo was able to earn money as a food delivery driver. 

In the early hours of 16^th April 2023 Leo was riding a 599cc Yamaha sports bike with an “Uber Eats” delivery box attached to the rear. He was not licenced to use such a motorcycle, which requires a full category A driving licence, with the licence holder being 21 years of age or older. Leo had been stationary on the motorcycle at a red light when approached by police. He made off at speed and subsequently lost control of the motorcycle, colliding with metal railings and sustaining injuries that caused his death. 

The MATTERS OF CONCERN are as follows:
1.  During the inquest evidence was heard that:
i.      There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence  to  deliver  food.  However,  there  appears  to  be  no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.  

2.  I have concerns with regard to the following:
i.          There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I heard is a national issue; 
ii.         As  a  consequence,  children  are  working  in  the  food  delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;  
iii.        That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death. 

In my opinion urgent 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, by 30^th January 2026. 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) [REDACTED] (Leo’s mother) and [REDACTED] (Leo’s step-father)  
(2) [REDACTED] (Leo’s father) 
(3) Chief Constable for Dorset Police 
(4) Independent Office for Police Conduct  (5) Dorset Child Death Overview Panel 

At the request of the Home Office, the initial recipient of the original report to prevent future deaths dated 23^rd September 2025, the following have also been sent a copy of the report: 
[REDACTED]  of the Department for Business and Trade
 
[REDACTED]  of the Department of Transport 
 
[REDACTED] of the Health and Safety Executive 
 
 [REDACTED] of the Department for Education 
 
 [REDACTED] of the Home Office 
 
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.