What happened
At about 08:00 on 29 September 2023 a school commuter coach left the northbound M53 on the Wirral carrying more than fifty pupils from Chester to two grammar schools. A 15-year-old pupil and the driver died.
The coach was built after 2001 and had belts. CCTV showed them largely unused, including the driver’s.
On 5 October 2023 the senior coroner for Liverpool and Wirral, Andre Rebello, issued a Regulation 28 report to the Secretaries of State for Transport and Education, before the inquest.
The outcome
The inquest concluded at Liverpool on 4 July 2024 with a road traffic collision conclusion. The coroner ruled the pupil more likely than not belted: post-mortem findings were consistent with belt use, and CCTV showed her still while many others were unrestrained. The driver had collapsed with ischaemic heart disease; no prosecution followed.
The departments answered jointly on 15 December 2023. Passengers aged fourteen and over commit an offence by not belting up. For younger children the driver is normally responsible, except in a large bus, where that duty does not apply. This was one, so nobody aboard had to belt the younger children.
They declined to close that gap: obliging a coach driver to police fifty children would be unfair and a distraction. Instead they promised a DVSA reminder to operators and a note in the DfE’s travel guidance for schools arranging transport, and confirmed it issues no guidance for schools on that travel, “as these are not health and safety issues in strict legal terms”.
What went wrong
Nobody owned the check. The two schools arranged the coach themselves; the statutory guidance is addressed to councils and is permissive, saying authorities “may wish to specify” belted vehicles.
The law split responsibility by age, then exempted the vehicle: older pupils answered for themselves, younger ones answered to the driver, and the driver stopped answering once the coach was large.
The regulator stopped at notification: operators must tell passengers belts must be worn, and nothing requires anyone to look.
What it teaches
Fitted is not worn, and worn is not checked. A contract specifying belted vehicles has bought equipment and no more. What matters is the line naming who confirms use, when, and what happens if nobody does.
Supervision needs a written boundary. Most schools assume their duty travels with the pupils; here the department’s own letter says the arrangement was the schools’ choice and the guidance was written for councils.
A coroner’s report is a lever, not a remedy. Two secretaries of state replied within months and changed little that would have prevented this death.
Questions for the room
- On your coaches, who checks belts before the vehicle moves, and does the contract say so or only that belts exist?
- When a pupil is belted and still dies, does your review separate the equipment from the practice?
- Which journeys happen in a vehicle where the law assigns the check to nobody, and what would you write into the contract instead?
Evidence and limits
Confidence: confirmed. Report 2023-0369 and the joint DfT/DfE response of 15 December 2023 were read in full from the judiciary’s PDFs on 7 November 2026. The conclusion, the belt ruling and the driver’s cause of death rest on BBC News’s inquest report of 4 July 2024; the coroner’s conclusion is unpublished.
The pupil is not named and no injury is described. The driver is not named, having been convicted of nothing. The schools are withheld: two named grammar schools on the Wirral identify her.
Our training in physical intervention and safe practice is built on the same question: who is responsible for a pupil once they leave your door.
Sources
- Regulation 28 report 2023-0369, Courts and Tribunals Judiciary, 5 October 2023 · https://www.judiciary.uk/prevention-of-future-death-reports/
- Joint DfT/DfE response, 15 December 2023 · https://www.judiciary.uk/wp-content/uploads/2023/10/2023-0369-Response-from-Department-for-Transport-and-Department-for-Education.pdf
- BBC News, 4 July 2024 · https://www.bbc.com/news/articles/cpwdx9nz74yo
Reviewed 7 November 2026.