VANCOUVER -- A coroner’s report into the death of a woman who was run over after falling from a party bus highlights issues with B.C.’s commercial vehicle inspection system and calls on the transportation minister to make changes to prevent another tragedy.

On Jan. 9, 2016, 23-year-old Chelsea James was one of 28 passengers on a party bus operated by Silver Lady Limousine as it travelled from Surrey to a nightclub in downtown Vancouver.

She stood near the door as the bus made a left turn from West Hastings Street onto Burrard Street.

“According to witness statements, Ms. James fell down the stairs of the vehicle as it turned the corner,” the report says. “As she struck the vehicle door, it opened abruptly and Ms. James fell onto the road, where she was struck by the vehicle’s right rear tires.”

She died instantly.

"She thought she was taking a means of transportation that night that was going to be safe other than driving. She didn't want to drive and that was the plan,” said Shelly James, Chelsea’s mother. “And they got onto this bus, which we found out was really an accident waiting to happen."

According to the coroner’s report, the bus involved had “a long history of door malfunctions and the carrier was issued with multiple repair orders.”

Commercial Vehicle Safety Enforcement (CVSE) is the provincial agency tasked with inspecting party buses and limousines, and ensuring safety-related repairs are completed.

The coroner’s report highlights gaps in the system of enforcing those repairs, and in the case of the bus involved in James’ death found that agency “received no proof of door repairs yet the limousine remained in operation.”

CVSE staff and Vancouver police inspected the bus after James’ death and both confirmed the door was defective.

The report makes a series of recommendations to Transportation Minister Claire Trevena, including that she consider implementing a tracking system at Commercial Vehicle Safety Enforcement to ensure repairs are completed and documented.

It also recommends the implementation of a quality management system at inspection facilities to make sure inspections are done to an approved standard.

“It infuriates me,” said Chad James, Chelsea’s brother. “They (CVSE) were the ones that were passing it on semi-annual inspections. The first one, they took it out because the door was faulty and six days later it passed its inspection with no proof of repairs. What’s with that?”

The Ministry of Transportation says work is already underway to strengthen the inspection and compliance processes, including software upgrades to make the system more efficient.

“In the meantime we continue to prioritize safety through tougher enforcement and inspections, reflected in the significant increase in safety inspections completed in 2019,” said Trevena in a statement to CTV News.

“Safety is my top priority, and I want British Columbia to become a national leader in commercial vehicle safety. While we have work to do, we are making progress and will remain focused on continued improvement.”

Nobody was ever charged criminally in James’ death and her family says because she was not married and had no dependants, they were unable to pursue a civil case against Silver Lady Limousine.

“Why weren’t people held accountable for these passes of a vehicle that was pretty much a tin can on the road?” asked Shelly James. “That breaks our hearts….to feel that Chelsea was just another number. And she wasn’t. She was a big part of our family.”