Prevention of Future Deaths reports · 2013

Luke Lyons

Regulation 28 report to prevent future deaths, reference 2013-0203, written 17 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Sep 2013
Reference2013-0203
DeceasedLuke Lyons
CoronerDr Elizabeth Earland
Coroner areaExeter & Greater Devon
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

eae

HM Senior Coroner for the County of Devon
Exeter and Greater Devon District

Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD.

Date: 17" September 2013
Sustainable and Safe Travel Team Manager

Devon County Council Our ref: © EAE/NLP

ABG Lucombe House File No: 247/2013
County Hall

Topsham Road Your ref:

Exeter

EX2 4QD

Re Luke James LYONS Deceased — DOD 25.01.2013
Inquest — 13.09.2013 at Devon County Hall, Topsham Road
Report pursuant to Regulation 28 Coroner’s and Justice Act 2009

I write following the Inquest into the death of Luke James Lyons who died on 25" J anuary
2013 at the scene of the accident just past Cove on the A396 when his vehicle hit a patch of
black ice which had formed overnight.

Tenclose a copy of the record of findings of Inquest, a recording and copies of the map of the
location and scale plan of the incident for information; along with the data contained in CS,
C6 and C7 regarding the gritting of the area.

I received evidence that the area in question was subject to water egress from the land at the
side of the road which flowed from the higher ground across the road, thereby washing away
any salt gritting put down by the Highway Department in anticipation of bad weather.

It was clear that procedures were followed, gritting undertaken which it was anticipated
would have satisfied the need for gritting the area in question in the absence of the localised
water problem.

I received evidence that a number of vehicles going through this area also lost control despite
the gritting but had managed to counteract the loss of control.

I understand that the Highways Department have since placed a drain at the location in order
to combat the problem but it appears that it is inadequate (from information received from

nn of Devon and Cornwall Constabulary). Clearly a repetition of
Luke’s death in the forthcoming winter would be a disaster if it could be avoided by further
action.

Exeter and Greater Devon Coroner's Office, Room 226, Devon County Hall, Topsham Road, Exeter, EX2 4QD
Telephone: 01392 383636 Fax: 01392 383635 Email: coroner@exgd-coroner.co.uk

I therefore feel it necessary to bring this matter to your attention pursuant to Regulation 28
Coroner’s and Justice Act 2009 and look forward to your substantive response within the
statuary 56 days.

I am copying this letter to the Chief Coroner and all Properly Interested Persons.

I await hearing from you.

Yours sincerely

AGA

Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD
HM Senior Coroner

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Devon County Council (PDF)
PF a0e[q 10}90N1g 2IBeyeNS

SIT AOB UOASp MAA
OZOL SSL SPg0 ‘euoYyd)xe]
jounod Ajunog uoneq ‘saynos Bunyes Areuonneseid Jno ynouGnosy) UsyeyepuN syuswjee}
au} JO Yoddns ul pue Je]UIM Ise] 9EE OU} UO Use} sjUsW}Ee jeoIsAYyd By} YA WepUe} U|

"SIY} JOS|jes seuwesBold yuSWyesI}
pue suojdedsul sno pue ainjnj ul yeedas 0} sjUsASe JaUJeEOM Jo sadA} osou} yOedxe op
om ‘Aiqeyeibey “Aemo6Beleo eu} saoge punoib seybiy ay} peyeunyes yeu} |Jeyules Jo spoied
peBuojoid pue 9wWeyjxe jo yINSe! ey} Useq sAey pjnom AemebHelweo su} Uo sayem Aue yeu}
s}se66ns seyunj siu] ‘senss! eGeulesp Bulunoes pajyou jou eAey suo}oedsul sno pue ‘orjqnd
ey} WOd Osfqns si} UO jUIe}dWION Jo soUspUodsslIO9D Jo AJO}SIY E USEq SBU S49} JEU} MOUS
JOU OP SpJooes No ‘UOeDO| SIU} Ty “AemeBeweo ay} UO Jayem Pode pue eAlasqo Aew OUM
S]SHOJOW WWO1y SJUSWILUOD PUe SsodUspUodseOD Aq paple ose suoOadsul yong ~‘ebeurelp
0} Bujejeas sanss! Aue ssaippe 0} ya8S pue JO} Yoo] Op suoHOadsu! uno Ajjuenbesuoo
pue Aemabeleo ou} Uo GHujurewiel Juatu}eed} By} UodN JUspUsdep s! swIGe1 Hulpeaids yes
INO ‘SUOIPUOD peyo|peid au} 0} ayeuO!Podod 9q 0} }yBNoY} aJem pue paemoljo) aiem Huljjes
Aseuoyneoaid Je}uim ym Huyeep Jo} seinpeooid uno ‘}es}! ysonbul ey} HuLinp pajou nok sy

‘punoJ6 seyBiy wo Buyeuewe seyem Buds pue
uoyeinyes punos6 0} Bulpes| poled seBuo) yonw e JeAo jeoidA} Useq ose pey jjejures AABOH
‘yyeyurea Aneay Jo ponied e Buimojjo} Jayyeom poo Aue uM BulBuajeyo paspul ssem ‘sunoy
Bulpecsid ay} ul pue ‘sA0D Je 96EVW au} UO ELOZ Alenuer gz UO SUOHIpUCD BuIA aul

“MO|aq SUA}!
QSOu} JO [2 0} puodsei 0} ajqe eq 0} paseajd we | ‘Je}UIM Buluod siy} 10j ssouparedoid
Jno 0} se pelinbue pue usye} suoNoe jeipawes ay} Jo Aoenbape ay} jnoge suoljsenb
pesies eaey ‘Ajjuenbesqns pue atu} ay} ye Yjog ‘AyWoujne Aemyfbiy ou} se jounog AjuNoD
uoneg Aq uojeoso| siyj ye usyxe} Seinseow 3y} UOdN payUsLULUOD ‘sUOI}IPUOD Bsey} pajoU
aAey NOA ‘suoippUOd HulAp BulBualjeyo AJA Ul payNses yeu} JoyyEom BWa}Xxe Jo poad e
BuLinp pue eAo9d ye Aemofewweo ggey Ou} UO pa1Nd00 paip SUOAT JIA] YOIUM Ul JUSPIOU! BY _L

‘yeok siuyj jo Avenue ul suok7 34N7
Jo yyeap pes 94} o}U! Jsenbul ANOKA Bulmoyjo} ELO7% Jequuajdasg / | Jo J9}}9] INOA 40} NOA yUeUL

¢boz Arenuer gz God — suod] sewer on] Jo yyeep 94} OJ! }SeNbul
94} Bulmoljoy G00Z FY BO1ISNC pue s,seUu0I0D gz UOHeINBeay 0} JUeNsind yodey

puepey aq seeq

€L07Z JOqUaNON g :a}eq

ddr @x4

Ja}exy

ddr ex4 peoy weysdo,
‘J8}8Xq . IIE Ajunog UoASG
peoy weysdo, 9cc WOON
eH Aunog SOHO SJ@UdIOD UOADG JE}edID pue 19}0xXy
esnoyH equuosny puevey Vaid

juawebeuelyy ayseqg 9g Juoudojengg jeydey ‘shemyBiy

‘ jpuno> AWUNoD

UOAIaG

102 AON 8. G3AIBIBY

Pi soye11g 2169}e4S
' , SITAOB UOASp
OZOL SSL Spgo <euoYydyxe |

nN

juowebeueyy sjsepq 9 JUaLUdOjeANq JeydeD = " ~

Ajasa0uls SINOA.
“OW [Jed 0} oyeyIsay jou op eseajd Uayew siyj ul soueysisse JoyyNy Aue Jo aq ued | J]

‘a1ayMes|e pejeeda
you si suoAq eyn7q Jo spueLy pue Ajwuey ouy Aq 39} Ssajjsip oy} yeu} BuLinsue spuemo} YOM
0} ANUNUOD |]IM 8M yey} pue — poled Ja}UIM Su} JO SUOI}PUCD BuIBUa];]eYyo ey} BuLNp ses)
JOU - SN 0} USOUIOD }seUBIY OU} JO S| YIOMJOU S,UOASG UO Sj}slJo}OW Jo aHessed ajes ou} JO}
BulplAold O} JUSLUPLULWOD INO JEU} SeyesJSUOLUSP SUJSOUOD INOA 0} asuodsei Alu yey} adoy |

“SJ9]/AC} O} UOEUJOJU! pue sojApe jUeLOdU! BulyeulWwessip 0} JUSLUPIWUWUOD JNO pue
pauinbes aq Aew yey} sounseow jeipawes Aue Bulyeniul pue ase Aayy se senssi BulAyquapl
Jo ajqedeo yjoq s| awi6a1 Uooadsul Jno yeu} pue Booed }seq Y}IM oul] Ul pul ayeuolodoid
‘QAjoayo si osuweiBoid Bunjes Aleuojneosid JojUIM JNO yey} BsoUapPYyUCO JNO ‘eyep
0} UOedo] Bu} ye SUOHOSdsUI BHeUIeJp jo BUIOD}NO 9} SI YORoldde siyj 10} ajeuoiel INO

"SUOIIPUOD JOUJLOM BJOAES
ul BUIAUP UBYM a1eo Hulye} jnoge sebessaw syeulwassip 0} eIPSW SU} 9sN ||IM 8M PUB JOJUIM
ul Bul][eAeJ} UO BdlApe aai6 0} S}Isqom JNO UO }! PoYsi|qnd pue soysued 0} Joyeo| & paynquisip
aaey aAj ‘BuloyUoW jeu} JO soUeNbesuUOd e se sussn peo Oajo1d 0} Alesseo0eu aJe se sdajs
yons eye} pue Aemabeiied siyj jo souUeWOLed ou} JO}UOW 0} SWia}sAs BuLiayjye6 aousbiij9ju!
pue sseooid uoljoadsul Jno asn 0} snuUod ||IM aM pue sooeJd Jseq pue saloljod ino
UM oul ul aluiBas Buyyes Aieuoyneseid Jno ayesedo 0} anuUOD |IIM a~Q ‘a0R)d Ul SAeY OM
soinjeay aHeuleip au} JO BSN OU} SPNjOU! aJOJasOU} POLiad Ja}UIM yL/ELOZ BY} JO} sueld iNO

‘uBISep sj! 0} Bulpioooe pue payoedxe se si ayep 0} paniasgo se syiom abeureip
ay} Jo soUBWJOLed aU} yeu} paysHes We | JEU} WIYUOS ‘aiojoJay} ‘ued [| “YE}UIM Bulwioo au}
JO} sn asedeid 0} sdjey pue asodind 10} jy useq sey yom 94} EU} BuLNsus 0} JUSLUPILULUOO
dno spayjel sjusweAoidu aBeuresp uno BHulmojjoj uoneso] siy} 410} UoNOSdsu! jo |sAa|
ano pue Ajimiey SuoA7 AW Aq 39} UISdU0D 94} YM ONoUyeEdWAs AjaulJUa Asunoo Jo We | “SAOD
ye apew uoUsAJO}U! 94} Jo Aoenbape ay} jo MaIA jeuosied © pessaidxe jou sey

HEB eu; pue suok ay Jo Ajjwey ap jo jeyeq uo cso RS 6575 OdW Aq pasies
SUIZOUOD OU} JEU} pueysuspun | “AemofHees oy} UO PeAJesqo UsEq SEY UONUSAJO}UI SIU}
Jo aunjrej @ Wood Buisue Jayem sseoxe ou pue peubisep se BuluoNoUN SI BAOD Je UON}USAIEIU}
94} yeu} yseGG6ns “aquisAoN pue J8qo}9Q ul peousLiadxe jjejuies Aneoy jo poled au} se
Ajyueoes se pue ¢10z Bulids wooly payonpuod ‘suoyoedsul aseyL “}NO Poles JBM SyJOM OU}
gous uoHoedsul juanbey 0} yoalqns useq jes}! sey UONUSAJEJUI Siy}) pue ‘“WoyNy aBeureip
SACI 0} SYS Sil} ye UBYeYepuN Useq sey yiOM ‘sUOAT Jy BulAjoAu! JUBpIOU! |e}e} BY} SUIS

“JeUIM Bulwwod ay} jNoYUBNoJU} enuUOd |}IM Sounsealu HOddns esau}
pue ‘pouied Ja}UIM 984} J8A0 BHesSAO BIPSW pPeuTe}sns pepnjoul sly] “se}UNOOUS 0} yOedxs
pinoo Agu} suol}!puoD Buyenes} NIIP 24} 0} SIOSN peos LO]e 0} SoiNsealW os pasn ose

Related reports

Other reports by Dr Elizabeth Earland

See all →

More reports categorised “Road (Highways Safety) related deaths”

See all →

Track Road (Highways Safety) related deaths

See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.