Patricia Hazell: Prevention of future deaths report

You are under a duty to respond to this report within 56 days of the date of this report, namely by July 14, 2026. I, the coroner, may extend the period if an appropriate application is made.

I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided.

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In my opinion, unless this risk is reviewed and addressed at a regulatory and design level, there remains a risk of future deaths.

On the 18 May 2026 I held an Inquest with a Jury.

The medical cause of death was confirmed as 1a. Bilateral bronchopneumonia, caused by 2. Hypertensive heart disease, and rib and spinal fractures following a fall

The Jury determined how, when and where Mrs Hazell died, finding that:
On the 9th April 2025, at Broadway Rail Station, Gloucestershire, Mrs Hazell fell from a coach, when the wheelchair access door she was leaning against was opened from the outside without warning or checks being undertaken.

The significant injuries Mrs Hazell sustained led to decreased mobility and a fatal chest infection which caused her death on the 25th May 2025 at the John Radcliffe Hospital, Oxford.
Their Conclusion was Accident.

As a result, the deceased fell from the coach and sustained serious injuries. Those injuries led to a reduction in her mobility. Subsequently, she developed a chest infection from which she died.
Evidence was heard that the operator had undertaken a risk assessment relating to the risk of falling from the access door when the door was in use for boarding or alighting, but not in circumstances where the door was simply opened from the exterior while the vehicle was otherwise stationary.

Following the incident, the company took steps within its control, including issuing warnings and notifications to passengers when disembarking (although it was accepted that notifications given when disembarking may not always be heard or understood) and changing seating practices so that non disabled passengers were not seated adjacent to the access door. Evidence was also given that any design changes to the door mechanism or safeguards were matters for the DVSA.

The MATTERS OF CONCERN are as follows:
During the course of the inquest I heard evidence giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken.

The matters of concern are as follows:
• The design and operation of wheelchair access doors on coaches may
permit the door to be opened from the exterior
• That risks of falling was dependant solely on giving warnings to passengers inside and checking whether a person is leaning against the door. Such warnings may not always be effective.
• Where operators have identified residual risk, they may have no ability to mitigate that risk through design or engineering controls, as responsibility for such matters lies with the vehicle approval and safety regime overseen by the DVSA.
• In those circumstances, there is a concern that similar incidents could recur involving disabled access doors on coaches, with the potential for serious injury or death.

For these reasons, I consider it appropriate to report this matter to the DVSA so that the safety aspects of disabled access doors on coaches may be reviewed in light of the circumstances of this death.

I also may send a copy of the report to any other person who I believe may find it useful or of interest.

I can confirm I have sent the report to:
[please do not use individual’s names, but instead roles/titles]
·    Mrs Hazell’s Family
·    The Coach Operating Company
·    Any other Interested Persons as appropriate

I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses.