Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0071, written 24 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 | 24 Feb 2014 |
|---|---|
| Reference | 2014-0071 |
| Deceased | Kenneth Aldridge |
| Coroner | Peter Bedford |
| Coroner area | Berkshire |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: West Berkshire Highways Authority 1 CORONER I am Peter James Bedford, senior coroner, for the coroner area of Berkshire 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 24th December 2012 I commenced an investigation into the death of Kenneth Gerald Aldridge then aged sixty eight years. The investigation concluded at the end of the inquest on 29th January 2014. The conclusion of the inquest was road traffic collision, the medical cause of death being blunt head injury. 4 CIRCUMSTANCES OF THE DEATH Mr Aldridge was the driver of a motor car involved in a collision with a second vehicle on the A4 near Woolhampton in West Berkshire. The A4 at the scene is a dual carriageway and the vehicles appeared to have come together side by side and, despite a relatively slight impact, Mr Aldridge’s vehicle left the road and crashed into a tree. At the time of the contact between the two vehicles, the other vehicle was preparing to turn into a service road separated from the A4 by a paved area and wooden fencing. There are gaps in this divide to allow vehicular access and egress to and from the service road. 5 CORONER’S CONCERNS During the course of the Investigation the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) For a vehicle to turn in to the service road running parallel to the A4 it would be necessary to slow considerably and then effect the manoeuvre. It is not possible to make a complete manoeuvre round to the left without then forming a u-turn which is not possible without either reversing and going forward again or encroaching onto the outside lane of the A4 to make a sweeping manoeuvre into the access. (2) In the course of the evidence, the Collision Investigator who investigated the crash 1 on behalf of Thames Valley Police suggested that the ability to make such a manoeuvre on a fast dual carriageway is potentially dangerous. While the Officer expressed concerns about turning in, he was also concerned about vehicles pulling out of the service road on to the dual carriageway. (3) The evidence therefore gave rise to concern at the appropriateness of having an access to the service road at such a location, particularly given a speed limit of 70 miles per hour at that point. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has 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 25th April 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 family of Mr Aldridge. You are 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 24th February 2014 Peter J. Bedford Senior Coroner for Berkshire 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.
Betchire Cc (OO N os 14 April 2014 Highways and Transport Mr P Bedford Market Street HM Coroner for Berkshire Newbury Yeomanry House Berkshire RG14 5LD 131 Castle Hill Our Ref: MCE/sc Reading Your Ref: Berkshire RG17TA Dear Mr Bedford Report to Prevent Future Deaths Thank you for your letter dated 24!" February 2014 concerning the Inquest report following the recent death of Mr Kenneth Gerald Aldridge on the A4 at Padworth. This section of the A4 has been the subject of some investigation, which | have outlined below: Speed Limits The speed limit on the A4 between the two A340 roundabouts was considered by the Council's Speed Limit Task Group at its meeting in April 2010 when it was agreed that further traffic survey information was required. This section was considered again in December 2010 when it was agreed to introduce a 50mph speed limit to cover the junctions with Beenham Industrial Estate and Beenham village. The task group also agreed that the existing speed limit on the remaining length of the A4, which included the dual carriageway, was appropriate. An objection was received during the statutory consultation and advertisement of the 50mph speed limit, which was considered by Individual Decision (ID) with the recommendation to install the 50mph speed limit. The recommendation was agreed but the decision was ‘called in' by five Councillors. A copy of the ID report is enclosed for your records. The reasons for call in were considered by the Overview and Scrutiny Management Commission during May 2012 when it was resolved that ‘the A4 Bath Road, Padworth, Proposed 50mph Speed Limit be referred back to the Portfolio Holder for Highways for reconsideration’. - Continued... Switchboard: (01635) 42400 | =c¢ reaner Document Exchange: DX 30825 Newbury “greener Minicom: (01635) 519001 West Berkshire Beacon\ 5 an Authority, Website: www.westberks gov.uk The reasons for call in and the reconsideration of the speed limit were considered again by the speed limit task group at its meeting in August 2012. This was followed by Individual Decision report (ID 2470 A) on 20" September 2012 when it was agreed ‘That the proposed speed limit is introduced with the start of the speed limit at the eastern end being located approximately 140 metres to the west of its advertised location as shown on Plan No SLR/10/04/002B (Appendix C)’. The matter was again raised at a meeting of the task group on 7 March 2014 to resolve if the section of dual carriageway needs to be reconsidered. The task group were informed of your report, local residents concerns and the recommendations in Traffic Management Assessment (TMA) 168. It was agreed that the speed limit does not need to be reconsidered but consideration needs to be given to the installation of pedestrian warning signs between the bus stops and measures to assist access and egress to the entrances within the length of dual Carriageway. Recorded Injury Accidents Within the latest three year period to the end of January 2014 there have been 8 recorded injury accidents on the A4 between the 50mph speed limit and 100 metres east of its junction with Ufton Lane. These resulted in 1 fatal, 2 serious and 5 slight injuries being received. Of these 6 were within 100 metres of the Ufton Lane junction and resulted in 2 serious and 4 slight injury accidents. 3 of the accidents involved eastbound vehicles. The other two involved the recent fatal accident and a slight accident when a HGV travelling eastbound changed lanes. | have checked the accident data back to January 1994 to determine the number of injury accidents that have involved entrances/exits and below is a summary of the results: e 1 accident occurred in April 1998 at Max’s Cafe when a vehicle failed to give way when entering the A4; e There have been no accidents involving the first service road entrance/exit; e There have been 3 accidents at the second service road entrance/exit, but these all involved U-Turning vehicles at the gap in the central reservation; e The third entrance at the Comfort Hotel is within the 5O0mph speed limit and therefore has been excluded from my analysis. These results do not indicate that the entrances/exits on to the A4 are particularly unsafe. Continued ..... Traffic Management Assessment 168 A TMA was undertaken on the dual carriageway section of the A4 during November 2013 and considered the recorded injury accident record, traffic speeds and volume and comments from local residents. It was recommended to improve the signing at its junction with Ufton Lane, and install an additional ‘No Entry’ sign. These works are identified for implementation as part of the approved Traffic and Road Safety works programme 2014/15. | have enclosed a copy of the assessment for your records. Access Improvements The two lanes for westbound traffic could be reduced to one lane so that traffic travels in the middle of the carriageway as shown on the enclosed plan TM213/001. This would have the effect of creating small deceleration lanes into accesses and improving visibility for traffic entering the A4. To improve access into the service road the first entrance could be blocked up and a new access created as shown on the enclosed plan 213/002. This would prevent ‘U turn’ manoeuvres. However this could have the effect of vehicles entering the service road at speed. Due to the change in the nature of the road it is Proposed to consult the local ward members and parish councils on the proposals and | will contact you again when | have received the comments to the consultation. | believe we are addressing the matters of concern described in your report but should you have any queries then please do not hesitate to contact me. Yours sincerely Head of Highways and transport | = ©
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