Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0114, written 13 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Mar 2014 |
|---|---|
| Reference | 2014-0114 |
| Deceased | Janette Sutherland |
| Coroner | Wendy James |
| Coroner area | Gwent |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ~] THIS REPORT IS BEING SENT TO: Mr. Stuart Rosser, Chief Executive, Caerphilly County Borough Council, Ty Penallta, Tredomen Parc, Ystrad Mynach, Hengoed CF82 7WF 1 | CORONER | am Wendy Ann James, assistant coroner, for the coroner area of Gwent 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 25-10-13 | commenced an investigation into the death of JANETTE SUTHERLAND (d.0.b. 20-02-65). The investigation concluded at the end of the inquest on 06-03-14. The conclusion of the inquest was Accidental Death. The medical cause of death being:- 1 (a) Multiple Internal Injuries (b) Blunt Vehicular Trauma 4 | CIRCUMSTANCES OF THE DEATH On 24-10-13 Ms Sutherland was driving her vehicle northbound along the A467 between the Ochrwyth and Full Moon roundabouts near Risca. Whilst exiting a sweeping left hand bend she suddenly and unexpectedly lost contro! of her vehicle. Her vehicle left the nearside carriageway and impacted with a concrete headwall located at the head of a drainage channel in the verge. Ms Sutherland as a result sustained fatal injuries. No safety barrier was present on the nearside of the carriageway. 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 presence of the drainage channel and concrete headwall represent a hazard to toad users and a safety barrier should be erected to prevent vehicles from leaving the carriageway and impacting with the concrete headwall. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 07-05-14, |, 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 ser i " ited Persons: | 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 tesponse, about the release or the publication of your response by the Chief Coroner. [DATE] [SIGNED BY GORONER] 13-03-14 WA Ore .
2 responses 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.
Penalita House, Ty Penalita, >» Tredomen Park, Parc Tredomen, Ystrad Mynach, Ystrad Mynach, CAERPHILLY Hengoed CF82 7PG Hengoed CF82 7PG CAEREEIE 14 JUL 2014 www.caerphilly.gov.uk www.caerffili.gov.uk Ms Wendy James Assistant Coroner (Gwent) Your Ref/Eich Cyf: Coroner's Officer Our Ref/Ein Cyf: Victoria Chambers Contact/Cysylltweh a: 11 Ciytha Park Road Telephone/Ffon: Newport ’ Date/Dyddiad: 9" July 2014 Dear Ms James Janette Sutherland Date of Birth: 20" February 1965 Date of Death: 24"" October 2013 We recently responded to your Regulation 28 Report and your request for the council, as highway authority, to consider potential measures that will serve to alleviate future incidents at the A467. As previously reported, a full topographic survey has been undertaken in order to accurately model the geometrical parameters of the existing highway along with all perceived hazards (ditch/headwall/rock-face). The results from this survey, along with traffic data obtained for the site, were input into software provided by the Department for Transport in order to satisfy the Road Restraint Risk Assessment Process (RRRAP). The result of this investigation deemed the headwall as being of significant risk, if struck by an errant vehicle, and that remedial measures should be implemented to reduce this. The ditch and rock-face were also modelled as potential hazards, although both yielded a negative outcome in terms of risk posed. It was therefore recommended that the risk posed by the headwall be reduced either by protecting with a vehicular restraint system or by removing the hazard altogether. Having considered the cost benefits of the alternative solutions, the decision has been made to demolish the headwall and re-profile the surrounding ditch in order to create an angled/‘soft’ landscape to the end of the channel/pipe (please find existing and 'mock-up' photos attached to illustrate this). | confirm these works are programmed for commencement in July. Agreener place Man gwyrddach | trust this meets with your requirements but please feel free to contact me should you have any further queries Yours sincerely ACTING DEPUTY CHIEF EXECUTIVE
Te / Cyfarwyddwr Corfforaethol Agreener place Man gwyrddach Penallta House, Ty Penalita, 0 A > \ Tredomen Park, Parc Tredomen, 7 APR 2014 A ERR. PE | Y Ystrad Mynach, Ystrad Mynach, COUNTY BORGUGH WILLY Hengoed CF82 7PG Hengoed CF82 7PG OF oe TS Sa aa CAERFFILi 4 www.caerphilly.gov.uk Ms Wendy James Assistant Coroner (Gwent) Your Ref/Eich Cyf: Coroner's Officer Our Ref/Ein Cyf: SA/KW Victoria Chambers Contact/Cysylltweh a: P| 11 Clytha Park Road Newport Telephone/Ffon: NP20 4PB E Mail/E Bost: chiefsec@caerphilly.gov.uk Date/Dyddiad: 2° April 2014 Dear Ms James Janette Sutherland Date of Birth: 20" February 1965 Date of Death: 24" October 2013 | acknowledge receipt of your Regulation 28 Report in relation the fatality that occurred at the A467 on 24th October 2013. We are always saddened by the incidents that result in injury and/or death and this fatality is no exception . Thank you for writing to us to identify your concerns and the need for the council as highway authority to consider this. In relation to items 5 and 6 of your report, Officers will be investigating the site in order to provide recommendations and potential measures that will serve to alleviate future incidents. A report undertaken at the request of Gwent Police concluded there was no departure in respect of design standards at time of construction and there is no mandatory requirement to implement changes in design standards retrospectively. In order to comply with current standards for dealing with the requirements for road restraint systems, a detailed survey must first be conducted at the site. The survey was carried out on the 27th March 2014 and the data will be retrieved as soon as possible for us to fulfil the Road Restraint Risk Assessment Process (RRRAP). We will endeavour to complete the RRRAP in a timely manner and will provide details of any findings/outcomes at the earliest opportunity. | trust this meets with your requirements but please feel free to contact me should you have any further queries. i onaen® may be in any language or form at ss ‘a ne cot | Gallwch ohebu mewn unrhyw iaith nev
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