Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0383, written 12 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 | 12 Dec 2013 |
|---|---|
| Reference | 2013-0383 |
| Deceased | William McCourt |
| Coroner | Robert Turnbull |
| Coroner area | North Yorkshire (West) |
| Category | Other 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. David Bowe
1
CORONER
I am Robert Turnbull, senior coroner, for the coroner area of North Yorkshire Western
Area
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.
INVESTIGATION and INQUEST
On 18th September, 2012, I opened an inquest touching the death of William David
McCourt, then aged 52 years. The inquest was concluded on 12th December, 2013.
The conclusion of the inquest was that Mr McCourt died from injuries sustained in a road
traffic collision, the medical cause of death being severe head injuries.
CIRCUMSTANCES OF THE DEATH
1) On the afternoon of the 15th September, 2012, Mr McCourt was riding his
3
4
motorcycle on the A6108 Reeth to Richmond road. It was a fine day with good
visibility. The motorcycle was being ridden at a speed appropriate to the road
conditions and within the speed limit.
2) On approaching a location known as Lowenthwaite Bridge Mr McCourt was
confronted with a patch of running water which was running across the road
from adjacent land. He lost control of his motorcycle and was thrown from it
sustaining injuries from which he died at the scene.
3) There had been a flood warning sign erected to warn motorists of the presence
of the water. However, the sign had fallen over some time previously and would
not have signalled a warning to Mr McCourt.
4) Evidence at the inquest established that the hazard created by this running
5)
water was a long standing problem and had been present almost continuously
since December, 2011. In February, 2012, it was reported by a local resident to
the Highways authority via their website. Another resident had contacted the
Highways authority by telephone on two occasions, on the second occasion, in
May, 2012, he was told that somebody would come out to investigate but heard
nothing more.
In June, 2012, a two car accident occurred at the same location. On this
occasion a Highways Maintenance Manager attended and spoke to people at
the scene. Flood signs were erected and enquiries commenced to establish
who owned the land and to require action to be taken to resolve the matter. It
appears that the maintenance manager believed that the land in question was
under the control of the Ministry of Defence. There was no written record of
what had been said on that occasion.
6) Between June, 2012, and the date of this accident there were numerous
telephone contacts between the maintenance manager and representatives of
the Ministry of Defence but nothing was resolved. It was after this accident on
15th September, 2012, that the Ministry of Defence finally stated that they did not
own the land in question. Over that period nothing had been sent to the Ministry
of Defence in writing requiring them to confirm ownership. This water continued
to run across the road, even in dry periods, between June and September,
2012, with no action taken to resolve the problem other than the erection of
1
signs.
7) This road was subject to monthly inspections. The inspection reports did not
mention the water on the road.
8) The matter was finally resolved following the accident when a police officer
visited the owner of the land and action was taken to clear a blocked drain.
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) No record was found of the reports made by local residents prior to June, 2012,
of flooding at this location either via the Highways website or by telephone on
two occasions and, therefore, no action taken.
2) The maintenance manager who visited the site in June, 2012, formed the
opinion that the land in question was owned by the Ministry of Defence. There
is no note of the conversation which led to this conclusion, neither did the
maintenance manager visit the occupier of the land from which the water was
flowing.
3) Over a three month period nothing was done to address the issue other than to
telephone the Ministry of Defence. The Ministry of Defence did not provide an
answer to the question of ownership of the land until after this accident when
they confirmed that they were not responsible for the land in question.
4) Nothing was ever put in writing to the Ministry of Defence requiring them to
notify the Highways Authority within a reasonable time scale as to whether they
owned the land and if so what action would be taken and by when.
5) This situation was allowed to ‘drift’ over at least a 3 month period prior to the
6)
accident.
Inspectors should have reported all potential hazards and actions taken to
address them.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you [and
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 14th 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
Department and
, Fentons Solicitors, North Yorkshire County Council Legal
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
14th January 2014
Robert Turnbull
Senior Coroner North Yorkshire Western Area
2
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.
North Yorkshire County Council Central Services Mr R Turnbull Senior Coroner 21 Grammar School Lane Assistant Chief Executive (Legal and Democratic Services) Northallerton County Hall, Northallerton, North Yorkshire, DL7 8AD DL6 1DF Contact: ay Tel: Fax: E-mail: Web: www.northyorks.gov.uk Our ref: | 12 March 2014 Your ref: Dear Mr Turnbull Regulation 28 — Report to prevent future deaths Inquest touching the death of Mr McCourt | write further to receipt of the above Regulation 28 report, and set out the Authority's response, below which address the points raised in section 5 of the above report. (1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly. (2) It was acknowledged at the inquest that on this occasion more detailed notes should have been taken and clearer direction is now being given to staff to ensure better records exist in the future. The Maintenance Manager, in this instance, was given every indication by the representative of the Ministry of Defence that they were responsible for the land in question and hence no further enquiries were made. It appeared that the farm buildings were unoccupied at the time the flooding event occurred. (3) and (4) — in relation to both of these point, it is acknowledged by North Yorkshire County Council that it would have been appropriate to put the position in writing and to confirm the expected remedial action and a timescale. (5) As set out above, it is acknowledged that advising of the original approach in writing to the Ministry of Defence would have been of greater assistance in seeking an agreed resolution to the issue of flooding. Lexcel Practice Management Standard A responsive County Council providing excellent and efficient local services Law Society Accredited HR/ 106393 / 129936 North Yorkshire County Council Central Services (6) North Yorkshire County Council’s highway officers record actionable defects (i.e those defects where work is intended) when carrying out inspections of the highway network. If temporary warning signs are in place to alleviate a hazard, the defect/warning signs should still be recorded until it has been resolved. Further advice has now been circulated to relevant highways officers through their managers to assert that this process is followed in future. | trust that the above points assist the Coroner in response to the report dated 14 January 2014. If | can be of any further assistance, please do not hesitate to contact me on the details set out above. Yours si for Assistant Chief Executive (Legal and Democratic Services) Lexcel Practice Management Standard A responsive County Council providing excellent and efficient local services Law Society Accredited HR/ 106393 / 129936
See every Prevention of Future Deaths report matching Robert Turnbull, 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.