Prevention of Future Deaths reports · 2014

Sean Morley

Regulation 28 report to prevent future deaths, reference 2014-0132, written 24 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Mar 2014
Reference2014-0132
DeceasedSean Morley
CoronerDavid Clark
Coroner areaWarwickshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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:

1. Mr Jim Graham, Chief Executive, Warwickshire County Council, Shire Hall,
Warwick CV34 4SA

CORONER

| am David Andrew Clark, Assistant Coroner for the Coroner area of Warwickshire.

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.

INVESTIGATION and INQUEST

On 4 September 2012, | commenced an investigation into the death of Sean Andrew
Morley, aged 20. The investigation concluded at the end of the inquest on 14 March
2014. The conclusion of the inquest was that Sean died as the result of an accident. The
medical cause of death was 1a. Multiple injuries including Severe Closed Head Injury.

CIRCUMSTANCES OF THE DEATH

Sean was crossing the A444 Bedworth By-pass on foot between 3am and 4am on 2
September 2012 when he was struck by a motor vehicle, the driver of which did not
remain at the scene.

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) | heard evidence that the stretch of the A444 where Sean died is regularly used by
pedestrians and cyclists, who walk or ride on the grass verge at the side of the
carriageway or on the edge of the carriageway itself.

(2) Since Sean’s death, there has been a further incident on the same stretch of road
where a pedestrian was struck by a car. Fortunately, the injuries were not fatal.

(3) There are no signs warning pedestrians or cyclists of the dangers of using the road.
There are no street lights. The speed limit on the road is 7Omph. There is no barrier or
other protective features between the vehicular traffic and pedestrians.

(4) These factors strongly suggest that there is a risk of further fatal collisions between
vehicles and other road users.

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. In your response to this report, | invite you to comment on
any immediate action which you propose to take to raise awareness of the risks to non-
vehicular road users, as well as longer-term action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19 May 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 and to the following Interested
Persons:

a se": mother and step-father)

| have also sent it to Detective Inspector EEE Warwickshire Police, and
Assistant to Mr Dan Byles MP (North Warwickshire and Bedworth), who may
find it useful or of interest.

jam 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.

DATE SIGNED BY CORONER

Responses

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.

Response from Warwickshire County Council
Lexcel 

NVLSTOR IN PEOPI.E

SOCIETY 

Printed on 100% recycled paper 

IN THE CORONERS COURT SITTING AT LEAMINGTON SPA 

INQUEST INTO THE DEATH OF SEAN ANDREW MORLEY 

RESPONSE OF WARWICKSHIRE COUNTY COUNCIL TO CORONER'S 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

1 , Mr Morley died as a result of a road traffic collision on 2 September 

2012, He was walking home after a night out along the A444 Bedworth 
bypass between Walsingham Drive roundabout and the junction with 
Sutherland Drive, and was struck by a car travetling from the Coventry 
direction, in the early hours of the morning. 

2.  The  following  is  the  response  of  Warwickshire  County  Council  to  the 
concerns  expressed  by  the  Coroner  in  paragraph  5  of  his  regulation  28 
report to prevent future deaths dated 24 March 2014. 

3.  It  is  accepted  that  during  the  course  of  the  investigations  into  the 
circumstances leading to Mr Morley's death, it became apparent that there 
is  evidence  of  pedestrian  footfall  along  the  A444,  in  the  form  of  a 
welltrodden  path  in  the  verge.  At  the  inquest  into  Mr  Morley's  death, 
evidence was given by a Road Safety Engineer on behalf of the County 
Council that a CCTV survey had been commissioned to determine the level 
of pedestrian and cyclist use. Analysis of this footage and the direction of 
travel of pedestrians is still to be carried out. 

4.  Evidence was also given that proposals to introduce a footpath to enable 
pedestrians  to  walk  between  Walsingham  Drive  and  Sutherland  Drive, 
separated  from  the  fast  moving  traffic  would  need  to  be  properly 
investigated through a feasibility study. A feasibility study is to be carried 
out by consultants on behalf of the County Council and the level of footfall 
provided  by  the  CCTV  survey  will  feed  into  this  study,  giving  a  clear 
understanding of the level of usage such a facility would attract. This study 
will consider the cost and benefit of the introduction of a footpath, given 
the limitations of the road safety budget. Included in the study will be the 
speed limitfor the road and  other factors such as street lighting etc. The 
feasibility study is expected to be completed by the end of September 2014. 
5.  The separate injury collision referred to in paragraph 5(2) of the Coroner's 
report,  has  been  investigated. This  incident  took  place  near  to  the  layby 
opposite  the  junction  for  Sutherland  Drive.  This  accident  involved  a 
pedestrian who was walking along the A444 from the Coventry direction 
towards Nuneaton. It is not clear from the police accident report how the 
pedestrian  came  to  be  involved  in  a  collision  as  there  is  insufficient 
information relating to the collision detailed in the police report. However, 
this collision will be considered when the feasibility study is completed, so 

 
 
 
 
 that  we  are  certain  all  reported  pedestrian  collisions  are  included  in  the 
analysis. 

6.  The location and usage of the layby raise other concerns. It is apparent that 
there are people being picked up or dropped off from vehicles in this layby, 
who subsequently walk across the A444 to or from premises off Sutherland 
Drive.  This  location  is  also  to  be  assessed  to  determine  if  it  would  be 
advisable  to  remove  the  layby,  in  order  to  prevent  the  pedestrian 
movements  across  the A444  in  this  location. A  CCTV  survey  has  been 
conducted, the results of which will be analysed and an assessment made 
of the layby and its viability. 

7.  At the inquest, the lack of warning signs to deter pedestrians from using 
this  route  was  discussed.  The  Traffic  Signs,  Regulations  and  General 
Directions 2002 which prescribe the types of sign permitted to be used on 
the highway, do not include signs for this purpose, that are approved for 
use on the highway. However, Warwickshire County Council has made a 
commitment  to  introduce  barrier  railings,  to  be  positioned  at  locations 
where the footway around the roundabout at Walsingham Drive terminates; 
and  warning  signs  that  are  designed  to  inform  pedestrians  and  other 
vulnerable  road  users  that  alternative  routes  are  available,  and  to  advise 
them of the dangers posed by walking or cycling along a dual carriageway 
with  a  70mph  speed  limit.  The  type  of  sign  proposed  is  to  inform 
pedestrians of the alternative routes, rather than a typical road sign, that is 
more  appropriate  for  drivers  to  take  heed  of.  It  is  therefore  considered 
acceptable to introduce such signs even though they will not confirm to the 
Regulations applicable for road signs. This work is currently at the design 
stage, and is expected to be introduced by the end of June 2014. 

Head of Law and Governance 
Warwickshire County Council

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