Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0220, written 30 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 | 30 Aug 2013 |
|---|---|
| Reference | 2013-0220 |
| Deceased | Jack William Payton |
| Coroner | Michael Rose |
| Coroner area | Somerset (West) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
41. STEVE GARGON Chief Constable Avon and Somerset Constabulary
CORONER
lam Michael Richard ROSE, Senior Coroner for the West Somerset area
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.
INVESTIGATION and INQUEST
On 13 November 2023, | commenced an investigation into the death of Jack William
PAYTON deceased at 85 years. The investigation concluded at the end of the Inquest
on 12 August 2013. The Conclusion of the Inquest was natural causes and the cause of
death was:
ja Ischaemic Heart disease
CIRCUMSTANCES OF THE DEATH
The deceased was driving home to Cossington after attending a dialysis session at
Taunton when at approximately 5.30 pm on 17th October 2012 his car veered off the
carriageway of the A38 road at Bathpool to go down an embankment on his nearside.
The incident was reported to the Police Control Room at Portishead ("Portishead") at
7.20pm but no action was taken after the report was downgraded to "schedule"
The deceased's absence was reported to Portishead at 8.51 pm by a member of his
family but although action was taken to check the A38 between Bridgwater and Taunton
the deceased was not found until 25 minutes after midnight the following morning
following a review of closed logs which led to a more precise identification of the scene.
The pathologist at the subsequent post mortem found the deceased died of Ischaemic
heart disease but was not able to confirm whether or not the deceased would have died
if his body had been found earlier.
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:-
At the Inquest two members of the control room staff at Portishead namely |
Dy their replies to my questions and
demeanour conveyed to me the distinct impression that the hours they worked together
with their case load had a detrimental affect on their judgement and subsequent
handling of this matter.
ACTION SHOULD BE TAKEN
That the existing hours of work in an enclosed environment, namely four shifts of 10
hours followed by two shifts of 7 hours should be examined by an experienced
physiologist to ascertain whether or not the work pattern is reasonable for people of the
age and experience undertaking this type of work.
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] 30-Vur, 12 [SIGNED BY CORONER] _—-
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.
we AVON AND SOMERSET CONSTABULARY (saa www.avonandsomerset.police.uk Police Headquarters, PO Box 37, Valley Road, Portishead, BS20 8QJ Telephone: 01275 818340 Facsimile: 01275 816112 Office Hours: 8am ~ 6pm 18" October 2013 Michael Rose Senior Coroner Blackbrook Gate Blackbrook Park Avenue Taunton, Somerset TA1 2PG Dear Sir - JACK WILLIAM PAYTON DECEASED : REGULATION 29 CORONER’S (INVESTIGATIONS) REGULATIONS 2013 RESPONSE | refer to your Regulation 28 report dated 30 August 2013 following your inquest into the death of Jack William Payton. You reported matters of concem regarding the current shift patterns for Communications Department staff within the Avon and Somerset Constabulary. This was as a result of the evidence of two members of staff leaving you with a distinct impression that their shift pattern was a factor affecting their judgement detrimentally at the time of the incident involving the death of Mr Payton. | have considered the matters of concern you have raised and what action you consider should be taken and will be taking the following action: 1. lam commissioning an independent assessment of the current shj its effects on staff. | currently anticipate this will be completed by a Human Scientist with Qinetiq who will be working in conjunction with [i the Force Medical Advisor from our Occupational Health Department who, as a specialist consultant physician, authored a dissertation on driving fatigue and shift work. It is anticipated this work will commence in January 2014, due to the availability of 2. Their report will be presented for initial consideration to Chief Superintendent I GN who )=sheads =the Communications Department, together with representatives from the HR Department who will review the findings and develop recommendations balancing the findings of the independent report with the demand profiles the organisation experiences, the resources we have available, our need to provide a 24 hour/365 day service, and any other business impacts. 3. These recommendations will then be considered at Force level by an appropriate group to decide whether they should be implemented or whether any other options should be progressed. Should a decision be taken to amend shift patterns there are specific timescales set out with staff associations involving consultation and notice periods. The impact of these could mean that the timescales for full implementation could take until July 2014. 4. We would, of course, be happy to share our findings and the outcome with you in due course should you wish to see them. The Constabulary recognises that working a shift pattern, particularly where that pattern involves working during the night, may cause a level of fatigue not experienced by non- shift workers. As such, the existing shift pattern was considered in order to balance the demand profile for service which exists across 24 hours, against available resources and the need to reduce the impact of shift working on staff. For this reason, the current pattern has forward-rotating shifts and sufficient breaks intended to minimise its impact on our staff. Commissioning the independent review | have outlined will, | believe, enable the Force to take an informed decision on any changes which may be required. If | can be of any further assistance in this matter, please do not hesitate to contact me. Yours sincerely Assistant Chi
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