Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0209, written 29 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 | 29 Aug 2013 |
|---|---|
| Reference | 2013-0209 |
| Deceased | Martin Leslie Brown |
| Coroner | Tom Osborne |
| Coroner area | Gloucestershire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
The Office of Tom Osborne Her Majesty’s Assistant Coroner for Gloucestershire 29" August 2013 British Board of Agrement Bucknalls Lane Garston Watford Hertfordshire WE25 SBA Dear Sir, Re: Regulation 28 Report to Prevent Future Deaths | am Mr Tom Osborne, Assistant Coroner, for the Coroner Area of Gloucestershire and | 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. _ The inquest into the death of Martin Leslie Brown was concluded on 21" February 2013. | returned a narrative verdict that he died of multiple injuries when he skidded on relayed road surface that was excessively slippery due to excess bitumen. This was in part due to a failure to carry out the resurfacing work correctly and a failure to recognise the fault before the road was reopened. 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. — (1) There may be a possible dispute as to the interpretation of BBA certificate number 06/H120 issued in respect of Milepave. (2) In para 3.1 of the certificate it suggests that the product can be used on roads with a posted speed limit of less than 40mph. The same paragraph Gloucestershire Coroner’s Court, Corinium Avenue, Barnwood, Gloucester GL4 3DJ Acting Senior Coroner: David M Dooley Asst. Coroners: Alexis J. Cassin, Sally Scanlon, Thomas R Osborne, Katy Skerrett refers to use on “rural roads” that may, of course, be subject to the national speed limit of 60 mph. (3) The certificate does not specify that the product should not be used on roads where the posted speed limit is greater than 40 mph. (4) My concern is that the correct use of the product Milepave is not clearly set out in the certificate and it may be used inappropriately because of the wording used in the certificate. In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, I, 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. | have sent a copy of my report to the Chief Coroner and to the Interested Persons who appeared at the inquest. 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. | await hearing from you with your response. Yours Singerely Tom Osborne Her Majesty’s Assistant Coroner for Gloucestershire This report is being sent to: Family NIG Insurance Fletcher’s Solicitors Gloucestershire Constabulary ORJ Solicitors Gloucestershire Highways Wragge & Co LLP Gloucestershire Coroner’s Court, Corinium Avenue, Barnwood, Gloucester GL4 3DJ Acting Senior Coroner: David M Dooley Asst. Coroners: Alexis J. Cassin, Sally Scanlon, Thomas R Osborne, Katy Skerrett
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.
21 OCT 2015 Our Ref: — 06/H120 9 APPROVAL INSPECTION TESTING CERTIFICATION 09 October 2013 TECHNICAL APPROVALS FOR CONSTRUCTION Mr Tom Osborne waren Gloucestershire Coroners Court : Corinium Avenue, Barnwood, Gloucester GL4 3DJ Dear Mr Osborne Re: Regulation 28 Report to Prevent Future Deaths Further to your letter dated 29 August 2013 relating to matters of concern arising from the inquest into the death of Martin Leslie Brown and my initial response dated 5 September, | would like to update you regarding the wording in the Certificate 06/H120 Miles Macadam Milepave. We have revised paragraph 3.1 and removed the reference to rural roads. The sentence now reads: Milepave is satisfactory for use as a surface course on highways with posted speed limits up to and including 40 mph The reissue of the Certificate with this revised wording will be completed by no later than 1 December 2013. In response to your concern that the Certificate does not say the system should not be used on roads with posted speed limits higher than 40 mph. Our Certificates are issued on a voluntary basis and they provide a platform for manufacturers to declare properties of their proprietary products that may fall outside of any National or International Standards. This information can be used to assist in making decisions on whether it is appropriate for specific sites or constructions, based upon third party statements, rather than just those of the manufacturer. It is our policy to state the circumstances and situations where, in our opinion the product is suitable for use. Any other situations are, therefore, by definition outside of the scope of the Certificate. The BBA is an organisation that offers technical approvals of systems and products and we are not linked to Road or Construction Authorities. We have no power to stop the use of any of our Certificated products being used on or in situations that are not identified in the Certificate. If a Certificate holder, Road Authority, Engineer or Architect, etc decide, based on the information available, to use a product or system then that is their decision. If we can be of any further assistance please do not hesitate to contact us. Yours sincerely Project Manager Agrenernl Geninciies installer Appiovcts reduc Cartier ISO Goo Certiicaben GE Marsing Product Tesi Eurepeed Pechnical Ansesaments Gieen Deal
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