Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0355, written 15 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Nov 2013 |
|---|---|
| Reference | 2013-0355 |
| Deceased | David Cox |
| Coroner | Sophie Cartwright |
| Coroner area | Derby & Derbyshire |
| 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 THIS REPORT IS BEING SENT TO: The Peak District National Park Authority CORONER Tam an Assistant Coroner with Derby and Derbyshire Coroner's Area. 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. INVESTIGATION On the 28% January 2013 an investigation was commenced into the death of David Allan Cox. The investigation concluded at the end of the inquest which took place on the 4‘ October 2013. The conclusion of the inquest was accidental death. The medical cause of death was 1a Death due to immersion. CIRCUMSTANCES OF THE DEATH Shortly after 8.30am on 24 January 2013 David Allan Cox was driving his Toyota Aygo vehicle registration eS fo: his home along an unclassified single track bridleway at Blackwell Mill, Derbyshire between Blackwell Mill Cottages and Wye Dale Car Park at Topley Head. Driving conditions were poor, the bridleway being covered in compacted snow and ice. David Allan Cox was driving at a slow speed as he approached the second over bridge as the bridleway bends 90 degrees sharply to the left. At the bend the vehicle ran wide onto the steep riverbank to the offside sliding down and rolling onto its roof into the river below. David Allan Cox was trapped in his vehicle for some 45 minutes and life was subsequently pronounced extinct at Stepping hill Hospital. Present in Mr Cox’s vehicle was also his daughter who managed to escape. I heard evidence at inquest that shortly after Mr Cox’s vehicle entered the water, vehicle which was being used to drive their son to school also left the bridleway at the same location on the bend and her vehicle also slipped down the steep slope of the river bank and overturned into the river below. My investigation revealed that the track at the point of the bend where the two vehicles left the road is ninety degrees to the left and is extremely narrow and acute with no margin for error. To the offside is a steep shale covered bank which falls 1.4 metres to the surface of the river at an angle of approximately 40 degrees. The forensic collision investigator PC a... evidence that it would appear that Mr Cox misjudged his speed on the approach to this bend possibly by only a slight amount and this has resulted in the vehicle sliding on the icy surface and onto the river bank where it would have been impossible to regain control. rca gave evidence that in driving on the bend as part of his investigation after the collision he himself as an experienced advanced driver was quite frightened driving along the track at the corner and found it a tense experience. I heard extremely helpful evidence from [go the Peak District Authority. Who told me that the track is owned by the Peak District Authority and extends % mile between its westerly point at Wye Dale car park and its easterly point at Blackwell Cottages located at the start of the Monsal track. P| gave evidence to me in respect of the changes that have already been implemented, namely additional signage at the start of the track advising that only residents vehicles are permitted to use the narrow track, 5mph speed limit signs, “Caution blind bend motorists sign your horn” signs and convex mirrors on the bends. A proposal to place a gate at the start of the track at the car park entrance was refused by Derbyshire County Council. The statement of set out that following the death of Mr Cox, the Authority met with the Residents on 27 February 2013 primarily to discuss the bank repair works and that in addition there was a discussion generally on how the track could be made safer. gave evidence that the Peak District National Authority has commissioned a report from a Hydrological geotechnical consultant from Silkstone Environment to carry out a survey with regards to the feasibility of track widening and bank strengthening along the length of the track but in particular at the bend at the viaduct where Mr and [MB vehicles left the track. This survey and report in respect of track widening and bank strengthening would be a precursor to consideration of whether any bollards, barriers or fence could be placed on the track and on the bend and it was envisaged that this would require a further report from a safety expert . MMB was unable to comment on any future steps or works but was able to confirm the funding of the survey and report of the Hydrological geotechnical consultant had been granted by the Peak District National Park Authority and that this survey and report would be considered in due course. —— also identified that in the event that any future works were identified then, as the bank works at the viaduct completed in April 2013 to try and combat erosion had required consents from the Environment Agency, Derbyshire County Council as Highways Authority, Natural England as this was a site of special scientific interest and Network Rail as owners of the viaduct, it was likely that any future works identified would require these agencies input. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion action should be taken to prevent those circumstances happening again or to reduce the risk of death created by them. In the circumstances it is my statutory duty to report to you the Peak District National Park Authority. The matters of concern are as follows and relate to the track at the point of the bend where the vehicles. left the track on 24 January 2013 being extremely narrow and acute, leaving no margin for error and creating a risk of other vehicles leaving the track and sliding down the river bank into the river below due to the absence of any barrier. There is no barrier or wall along the length of the bridleway between the track and the river and I had confirmed in evidence that there are in total three blind bends along the length of the bridleway. The presence of two further blind bends along the same track also causes me concern. The concern is that circumstances creating a risk of further deaths will occur or will continue to exist in the future relating to the risk of vehicles leaving the narrow bridleway at the blind bends and rolling into the river due to the track being extremely narrow and the absence of any barrier between the bridleway and the river below. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you the Peak District National Park Authority 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 10% January 2014. I 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. COPIES AND PUBLICATION T have sent a copy of my report to the Chief Coroner and to | have also sent this report to: 1. Derbyshire County Council 2. Environment Agency 3. Natural England 4, Network Rail As I set out at inquest, they may find it useful and of interest as | indicated to me in giving evidence that in the event that the Peak District National Park Authority determine works are required to the track then this will potentially require the consent for any works from the Environment Agency, Natural England, Derbyshire County Council and Network Rail as owners of the viaduct. Tam 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 may find it useful or of interest. You may make representations to me at the time of your response about the release or the publication of your response by the Chief Coroner. 15.11.13 Sophie Cartwright
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.
Tel: 01629 816263 Fax: 01629 816310 E-nai): Web: www.peakdistrict.gov.uk iS Minicom: 01629 816319 Aldern House . Baslow Road . Bakewell . Derbyshire . DE45 1AE PEAK DISTRICT NATIONAL PARK AUTHORITY Ms S Cartwright Your ret’ SC/ach/146/2013 Assistant Coroner Ourret: DS Coroner’s Court Date: 22 January 2014 5-6 Royal Court Basil Close Chesterfield Derbyshire $41 7SL RECORDED DELIVERY Dear Ms Cartwright Inquest touching upon the death of David Allen Cox Further to our letter of 30 December, we acknowledge receipt of your Prevention of Future Deaths Report, dated 15 November 2013. We note your observations within the Report and we are grateful for your acknowledgment of the safety measures implemented by the Authority since the accident. The Report outlines your concerns in relation to the nature of three bends along the track, including the bend at which the two vehicles left the road on 24 January 2013, and the lack of physical barrier between the track and the river bank. You have expressed concern that there remains a risk of future deaths relating to other vehicles leaving the road and entering the water at one of three aforementioned bends along the track and you have recommended that the Authority take further action to prevent those circumstances happening again. Your Report acknowledges that the Authority may potentially require the consent from the Environment Agency, Natural England, Derbyshire County Council and Network Rail (hereinafter referred to as the ‘Partners’) in connection to any works so determined. You have kindly provided a copy of your Report to each of the Partners to facilitate such consent. The Authority has carefully considered your Report, which echoes your comments made during the inquest on 4 October 2013, and has undertaken the following actions:- Actions Undertaken Post Inquest a. The Authority installed further permanent signage at both ends of the track in December 2013. The signage states “Public Safety Notice. Narrow track. Blind bends. Cycle with care. Expect to meet authorised vehicles’. A photograph of this signage is attached. Member of the Association of National Park Authorities Holder of Council of Europe Diploma “***" Chief Executive: Jim Dixon Chair: Tony Favell Deputy Chair: Geoff Nickotds Working together for the Peak District National Park: *A special environment «A welcoming place at the heart of the nation »Vibrant communities and a thriving economy = Any information given to the Authority may be disclosed under the Freedom of information Act 2000 b. Notwithstanding that the Authority has no policy to grit its bridleways or roads, save for inside the Monsal trail tunnels, the Authority has provided (and initially filled) two grit bins along the track. These are located north of the first viaduct on the track (marked in the approximate position ‘A’ on Plan 1 attached) and south of the second viaduct (marked in the approximate position ‘B’ on Plan 1 attached) respectively. The grit bins and initial grit were supplied by the Authority on week commencing 2 December 2013 on the basis that the residents of Blackwell Mill Cottages will apply the grit and subsequently re-fill the bins with the Authority providing a 25% contribution to the cost of such refills (with a cap of £100 per year). We understand that the residents have also arranged for a grit bin to be located at the residents’ car park. c. The Authority provided the residents on 20 December 2013 with 2 parking permits per household to enable them to park free of charge at the Wyedale Car Park at the entrance to the track during winter months should they wish to do so. Further permits are available on request and the permits will be renewed annually. d. The Authority has continued its monthly inspections of the track. The Authority has continued to keep and update a maintenance and inspection schedule of such inspections which have resulted in further pot hole repair works carried out on 27 September and 14 November 2013. e. The Authority made initial written contact with key organisations, including the Partners, on 3 December 2013 to inform them of the issues identified during the inquest, to put them on notice of the impending PFD Report and your emphasis of the need for their input into the consideration and approval of any action taken by the Authority. The key organisations were notified before receipt of the PFD Report and the expert reports (outlined below) to facilitate the implementation of any identified actions as soon as possible. The organisations contacted in early December are as follows: Environment Agency | Network Rail | Natural. England | Derbyshire County Council (‘DCC’) Chatsworth Estate (they have been identified as owning the river bed adjoining the track) o Buxton Fly Fishers Club who exercise fishing rights on the river adjoining the track (please see paragraph ‘m’ below). ooo0o000 Save for a meeting with representatives of DCC on 17 January 2014 (outlined further below) the Authority has not received a response from any of the organisations to date. f. Survey Report The River Wye Bank Stabilisation Works — Site Assessment Report (the “Survey Report”) was funded and commissioned by the Authority prior to the inquest. The report, which addresses bank stability and wider hydrological issues along the entire length of the track, was prepared by Silkstone Environmental Ltd and SM Foster Associates Ltd further to their respective stability and hydrological assessments. A copy is enclosed for your information. Although Silkstone carried out their initial on-site inspection on 16 October 2013, input from their sub-contractor and staff changes unfortunately resulted in the draft report not being produced until 21 November and the final report on 20 December 2013. The Survey Report indicates that the river bank is unstable at several locations along the 1km track due to water erosion, including at the incident bend. The report identifies the potential issues and solutions for bank stabilisation as well as the feasibility for track widening. The Survey Report confirms that the options for stabilisingAvidening works are complicated by the fact that the track is the sole egress for the residents of Blackwell Mill cottages and so any works must allow for short term closures only and the track must be capable of being opened in an emergency. The track’s width, construction and proximity to the river indicate that there will be continual issues with erosion and maintenance and it is suggested that engineering measures are necessary to improve the safety of the track for the residents. Three sites are identified as requiring such measures. The sites are shown on the attached Plan 2 and correspond to the aforementioned bends. The Survey Report recommends gabions (stones inside a metal mesh cage) as the most appropriate stabilisation method at each site, including the incident bend (Site 1). Potential for track widening (2.46m to 2.63m) at the incident bend and at Site 2 have been considered. The experts also suggest that the suggested bank stabilisation works will provide the track with sufficient stability to incorporate a fence/barrier along the embankment edge at Sites 1 and 2. A further gabion is recommended at the site of the existing gabion protection (Site/Priority 3). The report also appraises other possible engineering options, however, it is the intention of the Authority to pursue (subject to the necessary consents and funding) the installation of gabion walls as recommended. . The Survey Report was forwarded to the residents and the organisations listed above within paragraph ‘e’ on 16 and 17 January for comment by no later 14 February 2014. You will recall from the inquest that the Authority consulted with DCC and Natural England, and required consent from the Environment Agency and Network Rail, in respect of previous minor bank repair works carried out in April 2013. This previous process took 2 months and did not entail the extent of preparatory work or technical input required in respect of the works proposed within the Survey Report. In light of the much larger scale of the proposed works the Authority has requested consent from all of the Partners.. Present Position and Next Steps The following paragraphs set out the actions currently being undertaken by the Authority together with an outline of the next steps. h. Specification for Works Whilst comments/consents are awaited from the residents, Partners and organisations referred to above, the Authority has been in on-going discussions with Silkstone regarding the next phase of the regeneration works, that is the commissioning of a Specification for the proposed works. The Specification is a detailed document which sets out the design, materials and methodology for the completion of the proposed works. | | | : The consultants have indicated that, due to the complexity of the requirements of the preferred engineering solution, they require further input from a safety consultant, specialist gabion supplier and detailed design consultant and they have advised that going forward the project should be led by a specialist engineering firm. Unfortunately, Silkstone advised the Authority last week that due to the complexity of the proposed works they do not have the capacity or relevant insurance in order to complete the Specification. The Authority has therefore requested that Silkstone nominate and provide all relevant details of specialist engineering firms capable of compiling the Specification, managing the tendering process and taking the project forward. The Authority is currently actively chasing details of these nominated experts. Upon instruction of a suitable replacement of Silkstone the Authority will work with that expert firm in identifying the relevant safety consultant, gabion supplier and detailed design consultant with a view to ensuring the Specification is compiled appropriately and as soon as possible. This additional input will necessitate a variation of the original cost and timeframe for the production of the Specification. Silkstone had initially intimated that the Specification could be prepared within 1 month of receipt of a purchase order, however, in light of the additional expert input now identified the process is likely to take considerably longer. The Authority will forward a copy of the draft Specification to the Partners and organisations listed above together with the residents upon receipt for further comments and input. All relevant input will be referred to the instructed specialists for incorporation (if necessary) into a final draft of the Specification. The Authority can confirm that internal funds have been ring-fenced to pay for the development of the detailed Specification. Communication with Residents As above, the Authority has been in regular contact with the residents of Blackwell Mill Cottages regarding the track. Given the possible impact any engineering solution may have on the track, and access to the cottages during the works, the Authority will, in requesting comments, invite the residents to attend a meeting vith Property Development Officer for the Authority, to discuss the’ proposals. A meeting will be arranged upon receipt and distribution of the initial draft of the detailed Specification. The residents will not be asked to contribute to the cost of any such works. Tendering Process Upon finalisation of the Specification for the works the expert engineering company instructed to replace Silkstone will be commissioned to prepare the technical tender documents and a minimum of three appropriately qualified contractors will be invited to bid for the works in accordance with the Authority's standing orders. In addition to finalising the length of the works programme, the tender process will also quantify the costs of the proposed works. The tender process will take approximately 3 months from finalisation of the Specification. The Authority has also ring-fenced internal funds for the tender process, however, a contract for the works will only be awarded upon receipt of sufficient funding and any necessary consents. k. Consent and Liaison with the Partners Whilst the Authority has invited comments and requested consent from the Partners by 14 February 2014 it is likely that the Partners will not be in a position to confirm their consent fo the proposed works until receipt of the finalised Specification and the conclusion of the tendering process. The Authority will continue to pursue consents during the Specification and tendering process. It should also be noted, however, that any variations to the Specification required by the Partners, Chatsworth Estates, Buxton Flyfishers Club or the residents may have an adverse impact on timescales. |. Funding As stated at the Inquest, the Authority does not have the available resources to fund the proposed works. The Authority must therefore seek funding from external bodies. Although the Authority cannot bid for specific funding until the cost of the proposed works are known the Authority is in the meantime, investigating possible funding streams. In particular, the Authority is liaising closely with DCC as lead partners in the Pedal Peak II programme to discuss the feasibility of incorporating the proposed works into its scheme. A meeting was held with DCC on 17 January during which DCC expressed their agreement that the safety of all users of the track is paramount. Whilst DCC were not able to promise funds, it was agreed that they would consider the Specification to see how the proposed works would fit into their wider aims for the Pedal Peak Scheme. Further discussions are planned upon receipt of the Specification. m. Liaison with other Organisations In addition to the above, the Authority has also been liaising with the Buxton Flying Fishers Club which is investigating the possibility of carrying out soft engineering works (in the form of installing willow hurdles) to parts of the bank adjoining the track. It is estimated that, subject to the Club securing its own funding, such works may take place between January and March 2015. , Although the areas the Club is concerned with do not include the Sites identified in the PFD report or the Survey Report, and will not impact on these, the Authority is working with the Club to ensure that funding streams are not duplicated and, where possible, solutions can be found that are mutually beneficial to both parties. The Authority fully embraces the recommendations within the Prevention of Future Deaths Report and is committed to ensuring the recommended actions are progressed as a priority. This goal, however, is one which will require the active involvement, consent and funding from a range of parties including the Environment Agency, Natural England, Derbyshire County Council and the residents of Blackwell Mill cottages. We hope that this letter demonstrates the Authority’s commitment to improving the safety of the track for all users. Kind regards Yours faithfully Peak District National Park Authority
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.