Prevention of Future Deaths reports · 2013

Matthew Thomas Hamilton

Regulation 28 report to prevent future deaths, reference 2013-0180, written 8 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Aug 2013
Reference2013-0180
DeceasedMatthew Thomas Hamilton
CoronerD L I Roberts
Coroner areaCumbria (North & West)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

A.
Cumbria County Council,
Highways and Transportation,
Parkhouse Buliding,
Baron Way,
Kingmoor Business Park,
Carlisle. CA6 4SJ

1 | CORONER

| am David Llewelyn Roberts, Senior Coroner, for the coroner area of North and West
Cumbria.

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 2 September 2012 | commenced an investigation into the death of Matthew Thomas
Hamilton. The investigation concluded at the end of the inquest on 2 August 2013.

The conclusion of the inquest was:-

1a) Neck and Chest Injuries due to Road Traffic Collision.

4 | CIRCUMSTANCES OF THE DEATH

On the 2" September 2012 the deceased was riding his pedal cycle on the

footpath (No 109392) linking Harraby Grove and Brunel Way, Carlisle.

As he emerged onto Brunel Way he braked sharply as a car approached from his right.
He was thrown over the handlebars. Both he and the cycle struck the side of the car.
He sustained fatal injuries.

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. —

There is no barrier or restriction at the end of the footpath, such as are commonly found
on footpaths or at school gates. The pavement is only some 1.5metres wide. This

‘| means that children whether on foot or otherwise can emerge suddenly at speed Straight
into the line of traffic. It was also noted that the taller metal fence and shrubbery restricts
the vision of both footpath and road users. These represent hazards which should be

looked into, and some action might be taken to reduce the risk of future deaths. |

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 2™ October 2013. |, the coroner, may extend the period.

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.

az

COPIES and PUBLICATION

| have sent a copy of my report to t e following Interested
Persons and to the LOCAL
SAFEG ;

!am 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 who he believes may find it useful
€ coroner, at the time of your

response, about the release or the publication of your response by the Chief Coroner.

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