Prevention of Future Deaths reports · 2014
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 report | 24 Mar 2014 |
|---|---|
| Reference | 2014-0132 |
| Deceased | Sean Morley |
| Coroner | David Clark |
| Coroner area | Warwickshire |
| 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.
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
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.
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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