Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0176, written 17 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 | 17 Apr 2014 |
|---|---|
| Reference | 2014-0176 |
| Deceased | Paul Millis |
| Coroner | Donald Coutts-Wood |
| Coroner area | Leicester City & South Leicestershire |
| 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.
ANNEX A 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: 1. Director of Planning, Transportation and Economic Development, Leicester City Council, New Walk Centre, Welford Place, Leicester. LE1 6ZG 1 CORONER I am Donald Coutts-Wood, assistant coroner, for the coroner area of Leicester City and South Leicestershire 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 10th December 2013 I commenced an investigation into the death of Paul Millis, dob 17/12/1957. The investigation concluded at the end of the inquest on 09/04/2014. The conclusion of the inquest was the medical cause of death was: 1a Chest and pelvic injuries sustained in a road traffic collision. The conclusion was Road traffic collision. 4 CIRCUMSTANCES OF THE DEATH The junction of Troon Way and Nicklaus Road, in Leicester, was altered in 2013, with the works being completed and the new junction operational on 25th November 2013. The incident resulting in the death of Paul Millis occurred shortly after 2200 hours on 3rd December 2013. Paul Millis was travelling in a westerly direction on Troon Way, having finished work nearby at 2200 hours. He was travelling home, and continued through the junction in that westerly direction, riding a motorbike. As he went through the junction he was in the outer of the two lanes that progress on Troon Way. A motor car was ahead of him in the inner lane. When the two lanes merged Mr Millis has tried to either continue to overtake the car, or has started to overtake it. He travelled onto the opposing carriageway and struck a car in that carriageway head on. Evidence was given that a further serious incident has occurred at the junction since the 25th November 2013, which did not result in a fatality. 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. – 1 1. The merger of the 2 lanes occurs within a very short distance of the junction: approximately 35 metres. The process of merger by the 2 lanes is that the traffic moves in opposite directions – i.e. the inner lane moves to the right, thereby avoiding the verge, and the outer lane is directed by arrows to the left. 2. The westbound carriageway merges as described, and then as a single lane continues to the right until it straightens out into a single carriageway adjoining the eastbound traffic. The joining of the two flows of traffic occurs only 90 metres after the junction described above. 3. The situation described in 2 above means that any vehicle either behind another vehicle, or even beside it, will have a very delayed line of sight for traffic travelling eastbound, and likewise applies to eastbound traffic’s line of sight to a vehicle behind a first vehicle travelling westbound. As stated all of this movement of traffic is occurring in a very short distance and time. 4. It would appear that when the inner lane makes its sudden, very acute move to the right, that there is vacant verge area that would have allowed the lane to move less acutely. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR 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 Thursday, 12th 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 1. Traffic Management, Leicestershire Police, St Johns, Enderby, Leicestershire. LE19 2BR 2. 3. 4. 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 17/4/14 [SIGNED BY CORONER] ………………………………………….. 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.
Please ask for: Fe Direct line: _ _ = Email: Address: New Walk Centre, Welford Place, Leicester. LE1 6ZG Website www leicester.gov.uk Leicester Our ref: CD/PTED/ALS/JPB City Council Your ref: CEM/BLS/03648-2013 Date: 2™ June 2014 H.M. Coroner for Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester City Council LE1 9BG FAO. Mrs Catherine E. Mason Dear Mrs Mason, Re: Paul Millis. Thank you for your letter dated 17" April 2014 enclosing the Regulation 28 Report resulting from the Inquest of Mr Paul Millis. Firstly may | take the opportunity to express our deepest sympathy with the bereaved family and friends of Mr Millis following the toad traffic collision at Troon Way in December 2013. The Council takes its duty to maintain the public highway in a safe and serviceable condition very seriously and | have taken time to carefully review the concerns you have outlined in your report concerning the safety of the highway junction layout at Troon Way. The construction of a new junction layout at Troon Way and Nicklaus Road was a requirement of planning conditions for the new supermarket that has been built on land adjacent to Troon Way. The developer, Sainsbury’s Supermarkets Ltd, designed and constructed the works with technical approval from Leicester City Council as the Highway Authority. | can confirm and provide assurance that the highway design does comply with relevant standards, including the Design Manual for Roads and Bridges (Volume 6, Section 2, Part 3 - TD 50/04). | can also confirm that although the A563 Troon Way is not a trunk road, the higher design standards for trunk roads have been applied during the design process. In particular, the mandatory standards relating to visibility on approach to junctions have been met. The design of the junction layout was subject to three safety audits by an independent body to ensure that road safety implications are considered for all users of the highway. The safety audits were undertaken at the planning stage, the detailed design stage and upon completion of the works. The safety audit process necessarily involves consultation with the police and other stakeholders. PLANNING, TRANSPORTATION AND ECONOMIC DEVELOPMENT New Walk Centre, Welford Place, Leicester LE1 6ZG www.leicester.gov.uk A fourth safety audit is required to be undertaken after 12 months. This will take into account records of accidents and make recommendations for any changes where significant levels of risk to users are identified. Your report specifically includes the following detailed matters of concern which | address below: e The length of the merge on Troon Way for westbound traffic on the exit from the junction; e The direction that traffic moves when merging from two lanes to one on the westbound exit of the junction; e Visibility between westbound and eastbound traffic to and from the merge; and e The alignment of westbound carriageway on the exit from the junction. The Design Manual for Roads and Bridges advises that for trunk roads a merge length of 100 metres is recommended on the exit from a signalised junction. This is not a mandatory standard and is advisory. Troon Way is subject to a 40mph speed limit, as opposed to the trunk road network where signal design must accommodate higher speed limits. At Troon Way, the merge length of the two westbound lanes, measured in accordance with the standard, is 90 metres. Based upon the local circumstances, the highway designer, Highway Authority and the Road Safety Auditor considered this distance to be reasonable and in accordance with that which is experienced at other junctions throughout the United Kingdom. The Regulation 28 report notes that the merge requires traffic to move in opposite directions. It is usual practice for the outer lane to merge with the inner lane on the exit of a junction so that slower vehicles do not have to merge with faster moving traffic. This arrangement and alignment for the kerbs and road markings is common and is in place at other junctions in the City and elsewhere in the United Kingdom. With regards to visibility, the design of the junction complies with all mandatory requirements and is common. The street lighting is also to modern white light standards and provides enhanced vision at night time when compared to traditional yellow sodium light. In respect of the suggestion that the alignment of the inner lane makes a sudden, very acute move to the right, during the design process an appropriate length of merge was determined having considered the volume of traffic through the junction. However your comment will be forwarded to the Road Safety Auditor as it is appropriate in this circumstance to be taken into consideration during the final road safety audit. We have also received details from Leicestershire Police of their Collision Investigation Report into the accident. The report does not make any adverse comments in relation to the road layout, but will be made available to the Road Safety Auditor for consideration of the detail when undertaking the final road safety audit. | trust that this letter provides an acceptable response to the points raised in the Section 28 report including an explanation as to how the new junction layout complies with standards and how the design was subject to road safety audits. The fourth road safety PLANNING, TRANSPORTATION AND ECONOMIC DEVELOPMENT New Walk Centre, Welford Place, Leicester LE1 6ZG www. leicester.gov.uk audit, to be conducted after 12 months, will consider in detail reports of any recent serious accidents and incidents at the junction, along with their causes, to help identify any potential design and safety issues arising from the actual use and operation of the junction and make appropriate recommendations. Yours sincerely, Director of Planning, Transportation & Economic Development PLANNING, TRANSPORTATION AND ECONOMIC DEVELOPMENT New Walk Centre, Welford Place, Leicester LE1 6ZG www .leicester.gov.uk
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