Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0332, written 2 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2013 |
|---|---|
| Reference | 2013-0332 |
| Deceased | Karl Olof Nilsson |
| Coroner | Caroline Sarah Sumeray |
| Coroner area | West Yorkshire Western |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Head of Highways of Bradford Metropolitan District Council 2. Chief Executive of the Highways Agency 1 CORONER I am Caroline Sarah Sumeray, Assistant Coroner, for the Coroner Area of West Yorkshire (West). 2 CORONER’S LEGAL POWERS I 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 14th October 2012 I commenced an investigation into the death of Karl Olof Nilsson, aged 58. The investigation concluded at the end of the inquest on 27th September 2013. The conclusion of the inquest was Accident. The medical cause of death was found to be: 1a Multiple Injuries including Cardiac Tamponade and Flail Chest. 1b Road Traffic Accident. 4 CIRCUMSTANCES OF THE DEATH 1. The evidence in this case related to a road traffic collision that took place at around lunchtime on 14th October 2012 at the junction of the A657 Saltaire Road, and Victoria Road in Saltaire, near Shipley. The deceased was travelling on his motorcycle southbound on Victoria Road towards the junction of these two roads. Although the deceased was a Swedish national and was here in the UK visiting his family; he was familiar with the road on which he was travelling. He approached the junction at a speed of approximately 38 mph (as calculated by the Collision Investigator), which was slightly in excess of the speed limit of 30 mph. At the mouth of the junction (approached whilst travelling in a southerly direction) there is a STOP sign (a red octagonal sign on a yellow background), 1 2. The deceased did not appear to see the junction until too late when a car driven by which had stopped at the pelican crossing on the A657 Saltaire Road to allow pedestrians to cross, traversed slowly from west to east in front of him on the A657 Saltaire Road, causing Mr Nilsson to brake heavily before his motorcycle slid out from under him. The motorcycle crossed over the junction coming to rest on the other side, barely catching the rear of the car. Mr Nilsson was not so fortunate. He slammed into the side of the vehicle and suffered catastrophic injuries from which he died minutes later. 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. – 1. There are a number of factors which could, in my opinion have caused or contributed to this fatality. Victoria Road is an absolutely straight road which is aligned in almost a perfect north-south direction. It is a wide avenue type of road, with large trees visible on both the east and west pavements. On both sides of the road there are parking bays, and the cars are able to park fully on the road, whilst still leaving ample room for cars to pass in both directions. The layout is the same on both sections of Victoria Road – both before and after it is bisected by the A657 Saltaire Road. There is a gradient of approximately 1:7 stretching uphill from north to south. The slope of the road is only interrupted by the A657, which is perfectly level, but due to the slope of the road, it is not seen until the driver is approximately 20 meters from the junction. Moreover, due to the slope of the road, the STOP sign and stop line painted on the road is only really visible when the driver is approximately 20 meters from the junction. The overall layout of the road (i.e. it being perfectly straight with a sort of symmetrical appearance on both sides) contrives to almost create an optical illusion. The driver’s eye is drawn to the horizon in the centre – and as such, the STOP sign at the mouth of the junction is only in the driver’s peripheral vision. 2. I am concerned that the overall layout of this junction was a substantial contributing factor to this fatal accident. 3. I am concerned that the STOP sign is not clearly visible in its current 2 4. Furthermore, I understand from the evidence which was given to me that this is the only junction on the entire length of Victoria Road where the driver does not have right of way. It is possible that Mr Nilsson became confused as to where he was on Victoria Road. 5. I understand that since this fatal incident occurred, the Council has cut down the large tree next to the STOP sign at the junction, however it is my belief that the tree played no part in this accident. 6. The statistics presented to me during the course of the inquest that there have been 5 incidents where personal injury was caused at this junction in the last 3 years – Mr Nilsson’s was the only fatality 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th January 2014. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: who may find it useful or of interest. I have also sent it to Police Sergeant and I 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 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. 9 H.M. Assistant Coroner – West Yorkshire (West) area. 2nd December 2013 3
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.
Page 1 of 3 3 ~ Lo j\ 10 June 2014 11:22 ' Subject: FW: RE: Karl Olof Nilsson, Deceased. Report to Prevent Further Deaths Administrative Officer H. M. Coroner's Office West Yorkshire (Western) This email, and any attachments, may contain Protected or Restricted information and is intended solely for the individual to whom it is addressed. It may contain sensitive or protectively marked material and should be handled accordingly. If this email has been misdirected, please notify the author immediately. If you are not the intended recipient you must not disclose, distribute, copy, print or rely on any of the information contained in it or attached, and all copies must be deleted immediately. Whilst we take reasonable steps to try to identify any software viruses, any attachments to this email may nevertheless contain viruses which our anti-virus software has failed to identify. You should therefore carry out your own anti-virus checks before opening any documents. Bradford Council will not accept any liability for damage caused by computer viruses emanating from any attachment or other document supplied with this email. Emails may be subject to recording and / or monitoring in accordance with relevant legislation. Sent: 10 June 2014 11:17 To: HMC Subject: RE: Karl Olof Nilsson, Deceased. Report to Prevent Further Deaths Dear Mrs Sumeray RE: Karl Olof Nilsson, Deceased Report to Prevent Further Deaths Paragraph 7, Schedule 5 of the Coroners and Justice Act 200.9 and Regulations 28 and 29 of the Coroners (investigations) Regulations 2013 Thank you for your letter and attached report regarding the above matter. May I first apologise for the delay in responding as I have had a long period of illness and I am just getting back to normal duties now. Just to set the scene, I would first like to bring to your attention my background and involvement with this matter: I am Principal Engineer for the 6 Shipley Wards in Bradford, working for the Planning, Transportation and Highways Department. I have been in this role since 2006. I am lead officer on traffic matters within the council (policy and delivery) and I have a long standing involvement in Road Safety delivery. I also have various strategic and national roles: (cid:127) Chair of the West Yorkshire Casualty Reduction Partnership (Management of all the safety cameras in 10/06/2014 Page 2 of 3 West Yorkshire); (cid:127) Chair of the West Yorkshire Safer Roads Partnership (5 West Yorkshire Authorities come together to discuss Road Safety); (cid:127) Chair of Core Cities (All the Metropolitan cities in the UK come together to discuss Road Safety matters and feed back to the Department for Transport, who also attend); (cid:127) Member of the Parliamentary Advisory Council for Transport Safety (PACTS); (cid:127) Technical lead for the development of the Safer Roads element of the Local Transport Plan. I am also a member of the Child Death Overview Panel (CDOP) in Bradford and I have given evidence at the Transport Select Committee for the Strategic Framework for Road Safety document at Parliament. I have been aware of the junction and it's issues since 2008. During that time we have attended many meetings and carried out several investigations of the junction. The junction of Saltaire Road/Victoria Road is at the heart of Saltaire Village, this section also has World Heritage Status and it's a conservation area. This meant that any proposed changes to Saltaire would be passed through the conservation team and if deemed important enough, English Heritage. I concur with your assessment of the junction under Item 5, Coroner's concerns with the exception of 5.6. The trees (trunks and canopies) assisted with the avenue effect by masking the building lines at the junction. Therefore the optical illusion effect was enhanced by this. This was qualified by attending police officers at the time of the incident. Under my duties as Principal Engineer, I arranged for five trees to be removed at each corner of the junction. This immediately opened up the building lines and improved the visibility of the junction. A public realm scheme for Victoria Road has recently been awarded funding. This will involve the restoration of Victoria Road back to it's historical beginnings. One of the proposals is to remove all the trees for both sides of Victoria Road as the trees were a later addition to Victoria Road and did not feature in the original plan for the street. A consultation is currently taking place on this. As part of the public realm/safety improvements, a junction improvement scheme is about to be constructed (please find attached plan). The design incorporates stronger signing and lining and a clear, on-road demarcation of the junction from both approaches to Saltaire Road. An addition of detection loops to Victoria Road will assist with right turning vehicles into Saltaire Road. A puffin crossing 10 yards away from the junction will be triggered (l.e. a red light for the main flow of traffic on Saltaire Road) if two or more cars queue on Victoria Road. The situation will be closely monitored by my office post construction. If there is any further detail you require, please let me know at your own convenience. Yours sincerely Principal Engineer Traffic and Highways (North) Shipley Town Hall, 2nd Floor, Kirkgate, SHIPLEY BD18 3EJ City of Bradford Metropolitan District Council Department of Regeneration and Culture This e-mail, and any attachments, may contain Protected or Restricted information and is intended solely for the individual to whom it is addressed. It may contain sensitive or protectively marked material and should be handled accordingly. If this e-mail has been misdirected, please notify the author immediately. If you are not the intended recipient you must not disclose, distribute, copy, print or rely on any of the information contained in it or attached, and all copies must be deleted immediately. Whilst we take reasonable steps to try to identify any software viruses, any attachments to this e-mail may nevertheless contain viruses which our anti-virus software has failed to identify. You should therefore carry out your own anti-virus checks before opening any documents. Bradford Council will not accept any liability for damage caused by 10/06/2014 8 computer viruses emanating from any attachment or other document supplied with this e-mail. E-Mails may be subject to recording and / or monitoring in accordance with relevant legislation Page 3 of 3 10/06/2014 r e t l e h S n! 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