Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0170, written 1 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2013 |
|---|---|
| Reference | 2013-0170 |
| Deceased | Michael James Thornton |
| Coroner | Michael Rose |
| Coroner area | Somerset (West) |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The County Surveyor
2. Somerset County Council
3. County Hall, Taunton
4 CORONER
| am Michael Richard ROSE, Senior Coroner for the West Somerset area
2 | CORONER’S LEGAL POWERS
| 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.
3 | INVESTIGATION and INQUEST
On 13 November 2023, | commenced an investigation into the death of Michael James
THORNTON deceased at 30 years. The investigation concluded at the end of the
Inquest on 11 July 2013. The Conclusion of the Inquest was accidental death and the
cause of death was:
1a Drowning
1b Reduced Consciousness
1¢ Traumatic Head Injury
2. Ethanol Ingestion
4 | CIRCUMSTANCES OF THE DEATH
The deceased was a front seat passenger of a Landrover Discovery being driven along
Pill Road near Rooksbridge in the early hours of Tuesday 13 November 2012, ata
speed of not more than 30 mph when the driver swerved to avoid a Roe Deer,
subsequently causing the Landrover to leave the carriageway, cross a few feel of level
verge and enter the adjoining rhynne, landing on its roof.
The driver and the passenger in the rear seat were able to extradite themselves and
shortly after pulled the deceased from the vehicle and placed him on the underside of
the vehicle which was then lying between 2ft and 4ft above the water.
In the present case, although the driver was above the drink driving limit for alcohol he
was however a local and knew the road well and evidence was given that his driving had
not been a matter of concern to two witnesses and further that Roe Deer were present in
the area.
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
That ! have between one and two deaths per year from vehicles leaving the carriageway
and landing in a rhynne, often resulting in the death of the occupant by drowning and
therefore some action should be taken tp prevent future death. Although the erection of
retaining barriers along the sides of any carriageway to adjoining rhynnes might prevent
future accidents, the cost would be prohibitive and well beyond resources of the County
Council, given that there must be between 100 and 200 miles of roadway to be
protected.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action.
| therefore would like you to consider whether or not the painting of intermittent white
lines on either side of the carriageway might alert the driver to more readily appreciate
that he is likely to be leaving the carriageway.
In view of the costs involved such markings should only take place when a carriageway
is resurfaced.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report.
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.
|
COPIES and PUBLICATION
{ have sent a copy of my report to the Chief Coroner .
lam 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.
[DATE] ish Pix a we RS [SIGNED BY CORONER’
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