Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0147, written 3 Apr 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 Apr 2014 |
|---|---|
| Reference | 2014-0147 |
| Deceased | Melvin Bandtock |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr S Garlick, Chief Executive, Durham County Council, County Hall, Durham 1 CORONER I am ANDREW TWEDDLE, senior coroner, for the coroner area of County Durham and Darlington 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. (see attached sheet) 3 INVESTIGATION and INQUEST On 2nd April 2014 I commenced an investigation into the death of MELVIN BANDTOCK, Aged 55 years. The investigation concluded at the end of the inquest on 2nd April 2014. The conclusion of the inquest was “Accidental Death”. 4 CIRCUMSTANCES OF THE DEATH The deceased lost control of his motorcycle at approximately 09.11 hours on the morning of Saturday 28th December 2013 on the B6313 Craghead Lane, Craghead, County Durham road when he was travelling in an Easterly direction and when he lost control of his motorcycle after encountering a piece of black ice on the road which resulted in him being propelled down the road crossing onto the opposite carriageway and colliding with the front of a bus which was travelling in the opposite direction. At the time of the incident the bus was travelling at a speed of approximately 20 miles an hour and the motorcycle at a speed of approximately 28 miles an hour. The road had not been treated by the local authority as part of its gritting/salting regime. 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. – Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council’s own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have 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 10th June 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 following Interested Persons:- Durham Constabulary I 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. 9 3rd of April 2014 Andrew Tweddle LLB HM Senior Coroner County Durham and Darlington
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.
DURHAM CONSTABULARY Mike Barton LL.B. Chief Constable Chief Constable's Office 12 JUN 2014 Constabulary Headquarters A v f Aykley Heads iming for DURHAM EXCELLENCE County Durham DH1 5TT Tel. No.: (0191) 3752208 Fax No.: (0191) 3752210 Dx: 68850 Web Site: www.durham.police.uk E-mail: Your Ref: Our Ref: CC/CR Date: 10 June, 2014 Mn aaereres hen i Regulation 28 Notice This is a response to the Regulation 28 Notice sent to Durham Constabulary on the 3rd of April 2014 regarding the death of Melvin Bandtock on the 28th of December 2013 whilst riding his motorcycle on the B6313 Craghead Lane, Craghead. The matter of concern by the Coroner for the Constabulary was that the process for contacting Durham County Council was done by an individual call handler on an ad hoc basis with no monitoring or supervision. There was also a concern that there was no oversight that might lead a supervisory officer to conclude a potentially serious situation was developing on the County’s roads. This is not the case for both issues. The report of a road accident or of dangerous road conditions being reported by a member of the public would initially be taken by a call handler within the Force priority dispatch centre. That report would then be transferred to a dispatcher pod which has responsibility for deploying the most appropriate resources for a defined area of the County. If there was more than one report they would be taken by different call handlers but they would all be transferred to the same dispatch pod. NOT PROTECTIVELY MARKED Mr A Tweddle H.M. Coroner PO BOX 282 Bishop Auckland County Durham DL14 4FY Mb OVS ‘S - rd i POsiy ws be! [StreetSafe ] : INVESTOR IN PROLE “say The dispatchers for that area would then deploy officers to the incident and contact Durham County Council as appropriate. There is also a dispatch pod (call sign LA) which deals with all highways issues for the County. Any incident which was affecting the road network would have a ‘highways’ tag placed on it and would be managed in conjunction with the area response. The LA dispatcher, having overall view of the County’s road network, would normally be the dispatcher who would contact the Council, should issues become apparent. This would be recorded on the incident log so the area dispatcher would know this had been done and action was being taken. The dispatch room is overseen by 2 supervisors and an inspector is on duty at all times to manage critical incidents and firearms deployments. The duty inspector will also be able to contact the duty superintendent if a significant or major incident occurred. This means that if there was a serious situation developing then there would always be supervision available to manage it and an inspector or above to provide a strategic oversight. The lines of communication between the Constabulary and Durham County Council for road related issues are well established. The Constabulary receives daily e-mails of the winter maintenance programme and the contact details of the duty manager for the Council are on that e-mail. We also have the regular out of hours contact for clearing debris and other items from the carriageway when required. T/C! J from Durham and Cleveland Specialist Operations and cai met with Durham County Council Head of Technical Services, and reaffirmed that those arrangements are still in place and fit for purpose. As the main concerns expressed were that the Constabulary’s procedures for dealing with such incidents were managed on an ad-hoc basis, | would like to reassure you that this is not the case. | have confidence that we have robust, well managed procedures to deal with such reports as we receive them and also good lines of communication with our partners at Durham County Council to ensure their resources are deployed effectively. Yours sincerely Chief Constable 4 NOT PROTECTIVELY MARKED 2
Contact: Dreci Tek Durham Your ref: email: Our ret: Mr A Tweddle HM Senior Coroner for County Durham & Darlington HM Coroners Office ¢ PO Box 282 Bishop Auckland Co Durham DL14 4FY 4" June 2014 Dear Mr Tweddle Mr Melvin Bandtock, Deceased Thank you for your letter and Regulation 28 report dated 3 April 2014. George Garlick, Chief Executive, has asked me to respond as | am responsible for this service area. This was a tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Melvin Bandtock. In accordance with Regulation 28 we have considered whether any improvements can be made to our procedures to prevent future accidents. Statutory Duty Section 41(1A) of the Highways Act 1980 (c. 66) (duty of Highway Authority to maintain highway) states: “In particular, a Highway Authority is under a duty to ensure, so far as is reasonably practicable, that safe passage along a highway is not endangered by snow or ice.” The Council takes this very seriously and has an effective Winter Service Plan in place to meet this duty. Winter maintenance ts a top priority for the Council and despite major reductions in funding from central govemment this service has been fully protected and has benefitted from further investment. This is demonstrated by the fact that the Council treats 45% of its network which is one of the highest proportions in the UK. However, winter maintenance is not an exact science and the decision to deploy gritters for precautionary salting relies upon weather forecasts and professional judgement. Whilst weather forecasting has greatly improved in recent years it is not 100% accurate and the actual weather conditions on 28 December 2013 were worse than forecast which was a significant factor in this accident. Neighbourhood Services Durham County Council, County Hall, Durham DH1 5UQ Tel 03000 260000 (Minicom (0191) 383 3802 Text 07786 026 956 www.durham.gov.uk Page 2 of 3 Also, even when precautionary salting is undertaken there is no guarantee that it will be effective. The effectiveness of salting is dependent upon it being trafficked and weather conditions. In summary, the risk of danger from snow or ice and consequent accidents can never be completely eliminated. We can only reduce the risk as far as reasonably practicable. Matters of Concern Decision Making We would like to clarify that the Council is responsible for decision making and that our Duty Managers rely on the following information: e Weather forecasts; e Actual weather conditions from our weather stations countywide; e Intelligence on the ground from our Highway Inspectors. Reports from the Police are helpful and are acted on as appropriate but we do not rely on reports from the Police. Sharing of Information Following receipt of your letter we met with Durham Constabulary on 29" April 2014 to review existing information sharing protocols and to identify how these could be improved. | am aware that the Police are responding to you separately regarding this matter although | would like to assure you that there are effective communication mechanisms in place that enable us to manage our highways through partnership working. These protocols will be continually reviewed. Improved Margin of Safety We have reviewed our procedures and made a number of changes to improve the margin of safety against inaccurate weather forecasts and changing conditions: Communication When weather conditions are marginal, improved communication with the weather forecaster is essential, particularly when conditions deteriorate or change from that forecast. The Duty Manager will ensure that communication with the forecaster is meaningful in order that the extent and duration of the changes are fully understood and appropriate revised actions are implemented. The Council intends to meet with the forecasters prior to the next winter season to determine whether notifications relating to changes in weather can be improved. Amber Warning In circumstances where weather forecasts indicate an amber waming less than or equal to ic, with either high or tow confidence, Duty Highway Inspectors will be deployed on standby at the key strategic depots for the purpose of monitoring forecast information and where appropriate to undertake a route inspection to assist the Duty Manager in the decision making process. Page 3 of 3 In circumstances where weather forecasts indicate an amber waming less than or equal to i°c, with low confidence, winter maintenance vehicles will be deployed on standby at all strategic depots in readiness for gritting activity, therefore should weather conditions deteriorate from that forecast, an immediate gritting response can be implemented. Safety First Reminder Duty Managers have been reminded to ensure that appropriate action is taken and must at all times ensure that the safety of the highway network is the paramount consideration. Should there be any doubt with regards to the decision making process, the Duty Manager should always take a safety first approach and ensure the appropriate resource is in place to respond to changing conditions as quickly as is practicable, | hope the above reassures you that Durham County Council is committed to providing an excellent winter maintenance service so far as is reasonably practicable. Yours sincere! Corporate Director - Neighbourhood Services ce: George Garlick, Chief Executive a Head of Legal & Democratic Services Foy Head of Technical Services Chief Inspector, Cleveland & Durham Specialist Operations Unit, Durham Constabulary
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