Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0049, written 3 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2014 |
|---|---|
| Reference | 2014-0049 |
| Deceased | Daniel Jones |
| Coroner | Stephen Nicholls |
| Coroner area | Dorset |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HS Head of Dorset Highways Management, Dorset County Council, Dorchester 4 CORONER lam STEPHEN NICHOLLS, assistant coroner, for the coroner area of Dorset 2 | 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. 3 | INVESTIGATION and INQUEST On 30" May 2013 Mr Sheriff Payne, Senior Coroner for Dorset opened the investigation into the death of DANIEL WARWICK JONES, date of birth 25/02/1990. The investigation concluded at the end of the inquest on the 22/01/2014 heard by Mr Stephen Nicholls. The conclusion of the inquest was the deceased died of multiple injuries in a road traffic collision. 4 | CIRCUMSTANCES OF THE DEATH The deceased had been riding a motorcycle on the A356 from the direction of South Perrott towards Maiden Newton. As he approached the junction with a side road Toller Lane leading to Toller Porcorum his motorcycle was in collision with a motorcar that was travelling in the same direction. The motorcar was turning right off the A356 into the junction leading to Toller Porcorum. 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. — The court heard evidence from the car driver and her passenger, a rider of another motorcycle who was out with the deceased, two further independent witnesses and finally the Police Officer who conducted the accident investigation. It became clear from a number of witnesses who used the road on a regular basis that they were aware that there was a junction at this point but were unaware of the roadside warning triangle sign to indicate a junction or of the white arrow painted on the road surface to direct traffic travelling in the same direction as the deceased to pull into the nearside carriageway. This road is subject to 60 mph speed limit. Consideration needs to be given to improving the signage at this junction. Either by marking double white lines on the A356 to tell users that they must not overtake or improving the size and position of warning triangles indicating there is a junction, or both of those improvements together with anything further that would prevent a further accident at this junction. Further whether the speed limit at or around junctions on this road need to be reduced. The Police Officer who is an experienced road traffic officer who has to provide accident reports to the Coroners and other Courts was of the view that the signage at all junctions along the A356 may need to be considered. The inquest of course only heard evidence in connection with this junction. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 30" March 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner. | 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. 3 February 2014
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.
Dorset County Council Sse
Mr S N Nicholls
The Coroners Court
Stafford Road
Bournemouth
Dorset
BH1 1PA
Dear Mr Nicholls
Re: Inquest into the death of Daniel Warwick Jones
Dorset Highways
County Hall, Colliton Park
Dorchester
Dorset DT1 1XJ
Telephone;
Minicom:
We welcome calls via text Relay
Email:
Dx: DX 8716 Dorchester
Website: www.dorsetforyou.com
Date: 24 March 2014
Askfo: —_’
My ref: MWW/kjg/TE/2014/L13
Your ref:
{ am writing with regard to the actions we propose to take following receipt of your report into the
death of Mr Jones as a result of a road traffic collision on 26 May 2013 at the A356/Toller
Porcorum road junction in Dorset.
Since receipt of your letter and report, experienced officers in the Traffic Engineering have
investigated this matter and produced an action plan for this location and route. Please find
attached our report as to the actions to be taken and comments on further questions raised in
your initial report.
| trust that this information is of use to you. If you have any further questions please do not
hesitate to contact me.
Yours sincerely
Head of Dorset Highways Management
Enc.
Interim Director for Environment Mike Harries
RECEIVED
26 MAR 2014
i ~y INVESTORS
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Regulation 28: Report to Prevent Future Deaths (1)
Dorset County Council Response
Inquest into the death of Daniel Warwick Jones on 26 May 2013 which occurred on the A356
at the junction with Toller Lane.
Following the letter received from Mr Nicholls, Assistant Coroner, dated 3 February 2014
(ref SJN/LJ/450-2013) enclosing Annex A - Regulation 28: Report to Prevent Future Deaths,
the County Council responds with the comments and actions detailed below:
| can confirm that the County Council, as the local highway authority, has the power to erect
traffic signs under the Road Traffic Regulation Act 1984 and that they shall conform to the
Traffic Signs Regulations and General Directions 2002 (SI3113).
The County Council wili erect additional 'Side Road Ahead' warning signs on the offside, on
both approaches to the above junction, along with distance plates at the first of the existing
deflection arrow road markings. A'SLOW' road marking will also be laid for eastbound traffic
on the nearside.
The 'Matters of Concern’ are noted, however it is very common for road users not to notice
traffic signs and road markings on roads they use on a regular basis since they are so
familiar with the conditions they are likely to encounter. Traffic signs tend to be used by
those who do not normally travel a given route.
The road is subject to the national speed limit since this is appropriate to the class and
conditions generally found along the A356. Lower limits are used to protect communities
from traffic travelling at unreasonable speeds in built-up areas. 50mph limits are used on
some routes or sections of road with a poor collision record but this does not apply in the
case of the A356 in Dorset.
A lower speed limit through junctions on this road would not be readily understandable and
therefore, seem unreasonable to drivers so they would be unlikely to conform. Indeed, they
may even contribute to incidents similar to the one in question, where a driver slows to
comply and another uses it as a chance to overtake. They may also give rise to an
unreasonable expectation of enforcement and if this does not happen the limits would rapidly
fall into disrepute and be routinely ignored.
The provision of double-white lines through the junctions, such as the one where the fatality
occurred, would be contrary to the guidelines issued by the Department for Transport. Such
measures are to be used where there is a visibility problem such as at bends or dips. They
are also used to protect right-turn lanes and on three-lane roads. Their use through a
junction where visibility is very good is likely to bring them into disrepute leading to non-
compliance.
In general, the major junctions on this part of the A356 are treated in a consistent manner
with regard to signage and it must be pointed out that this fatality is the only recorded
collision involving personal injury in the last fifteen years at this particular junction.
After every fatality an experienced member of the Traffic Engineering staff meets a Police
Officer to see if there are any factors regarding the condition of the road, signs and road
markings which may have contributed to the collision. The resulting report forms part of the
report prepared for the Coroner by the Police. In this case no further action regarding such
matters was recommended.
To summarise, the existing signage will be augmented by signs on the offside to alert those
who might be overtaking to the presence of the junction ahead at Toller Lane. The existing
deflection arrows and thickened centre line will have a 'SLOW' road marking laid opposite
the new sign for eastbound traffic.
Unfortunately, the other suggestions contained in the Report to Prevent Future Deaths would
not conform to the policies and guidelines issued by the Department for Transport or the
County Council in this instance.
RMS/SJC/4268
24 March 2014
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