SINGAPORE - A routine furniture delivery ended in tragedy when the driver of the delivery van stepped in front of the vehicle while waiting and was run over and killed by it.

The State Coroner in an inquiry into her death said that Madam Chong Lee Wan had not fully engaged the handbrake of her van on a downhill slope at Pearl Bank Apartments before stepping out of the vehicle on Feb 11, 2017.

Madam Chong, 54, who was involved in the management and operations of her family business, Cristar Furniture, had walked towards the front of the vehicle while her son, Mr Lim Hsien Ern, had gone upstairs to deliver an office chair.

During the inquiry on Friday (Aug 4), State Coroner Marvin Bay said the van, which had the gear in neutral mode, moved forward and ran over Madam Chong when she tried to stop it with her hands.

The coroner, who found her death to be a tragic traffic misadventure, said: "Given this, the brakes were not in a position to effectively stop the van from rolling downwards... I would therefore attribute the inclination of the pick-up and drop-off area, as well as the inadequate engagement of the handbrake to be the prime contributing factors for the mishap.

"The actual movement of the van... was likely triggered by the closing of the driver's door, which caused the said vehicle to move forward and subsequently run over Madam Chong."

Madam Chong and her son arrived at the driveway of Pearl Bank Apartments in Pearl Bank road near Chinatown in a white Opel Vivaro van at around 10.10am that day.

Mr Lim recalled that he heard a click sound when his mother engaged the handbrake.

Madam Chong remained near the van while he went upstairs to deliver the chair. But the vehicle was nowhere to be found when he returned about 10 minutes later.

The security guards nearby told him that the van had rolled downhill and he later found his mother lying in the middle of the sloped road. The van was found about 50m away from where she had parked it.

Madam Chong was unconscious when an ambulance took her to the Singapore General Hospital where she died from multiple injuries about an hour later.

Coroner Bay said that according to senior automotive engineer Tan Jiat Shee, who later examined the van, the handbrake lever was found to be at the first click position during the inspection.

At this position, the handbrake would be ineffective and the rear wheels would still be able to turn.

The coroner added: "At the second click position, the rear wheels can still be turned with force and at the third click position, the rear wheels cannot be turned by hand.

"(Mr Tan) opined that the full application of the handbrake - at six clicks - should be applied when parking the vehicle."

Quoting the Workplace Safety and Health guidelines, Coroner Bay said drivers should park their vehicles at designated parking areas which should be level, firm, well-lit and clearly marked.

He said: "Drivers should ensure their vehicles are properly parked with the brakes engaged, engine turned off, starter keys removed and load or equipment lowered and secured."

If drivers need to stop or park their vehicles on a slope, they should also engage the gears - if it is safe to do so - and use wheel chokes, said Coroner Bay.