Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0193, written 28 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 | 28 Apr 2014 |
|---|---|
| Reference | 2014-0193 |
| Deceased | Yasmin Richards |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Mr Graham Dolton, Chief Executive, The Highways Agency 2. Chief Coroner 4 | CORONER lam Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon 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 8th November 2013 | commenced an investigation into the death of Miss Yasmin Mary Richards age 21 years. The investigation concluded at the end of the inquest on 20th March 2014. The conclusion of the inquest was that the medical cause of death was \(a) Chest injuries and the short-form conclusion was that the death was due a ‘Road Traffic Collision’. 4 | CIRCUMSTANCES OF THE DEATH The circumstances of Miss Richard’s death was that on 2nd November 2013 she was driving her Ford KA EM south along the A46 between Nimlet and Bath. She was alone in the car at the time. As she was negotiating a left hand bend in the section of the A46 known as the ‘Hartley Bends’ she lost control of her vehicle and crossed over into the the opposing carriageway. At the same time a Range Rover was travelling in the opposite direction and was unable to avoid the oncoming Ford Ka. A collision occurred between the two vehicles and as a result of the collision Miss Richard's received injuries from which died at the scene. She was pronounced dead at 10:00 hours. The driver of the Range Rover was physically uninjured. During the Inquest | heard evidence from witnesses to the collision as well as from a of the Collision Investigation Unit, Avon & Somerset Constabulary who conducted the collision investigation. In evidence | heard that the weather at the time of collision was overcast and dull. The road surface which was in a good state of repair was wet although it was not raining. There was no evidence to indicate that Miss Richard’s was travelling in excess of the prescribed maximum speed limit of 60 m.p.h. at the time of, or before, the collision. The Ford Ka was examined by a specialist vehicle examiner of the Collision Investigation Unit who reported that both the front tyres and the rear offside tyre were worn on the inner tread below the legal limit. It was also reported that the tyres were under inflated with pressures of around 50% of the recommended pressure. There were no other defects identified in the vehicle. | found that the condition of the tyres made a significant contribution to to causation of the collision in combination with the speed of the vehicle and the inexperience of the driver. 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) Notwithstanding the contribution made to this collision by the condition of the tyres of Ford Ka this is the second Inquest | have conducted within the past 12 months into the death of a driver who lost control of their vehicle on the same section of the A46. (2)The speed limit in the section of the A46 known as the 'Hartley Bends’ should be reviewed and reduced so as to improve the safety of drivers as they approach these bends. (3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the severity of the approaching bends. (4) Consideration be given to the provision of ‘rumble strips’ in advance of the bends so as to further encourage the reduction in the speed of vehicles as they approach the bends. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 23rd June 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. + 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: A (P2ren's of the Deceased). lam 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 | 28th April 204 Assistant 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.
HIGHWAYS AGENCY Safe roads, reliable journeys, informed travellers Our ref: 227-14 Chief Executive Your ref: 03784/2013 Federated House London Road Dorking Dr Peter Harrowing RH4 1SZ HM Assistant Coroner The Coroner’s Court www. highways.gov.uk The Courthouse , - Po Old Weston Road Direct Line: Pex Bourton 18 June 2014 Dear Dr Harrowing, Thank you for your letter of 28 April 2014, addressed to Graham Dalton, about the inquest into the death of Miss Yasmin Mary Richards and specifically the recommendations made under regulations 28 and 29 of The Coroners (Investigations) Regulations 2013. | am replying while Mr Dalton is away from the office. In responding to your recommendations, | shall set out the considerable improvement work: that has been done on the A46 at this location since 2 November. In addition | shall detail the future intended actions together with a timeline that the Highways Agency intend to pursue. May | take this further opportunity to extend our sympathies to Miss Richards’ family following this tragic incident. The safety of the travelling public is a priority for us and any incident, particularly one as serious as this, is regrettable and a cause for concern. On that basis we continuously monitor our entire network in terms of its condition and safety profile and where appropriate develop engineering solutions. In 2010/11 we received the A46 Route Safety Study that covered the entire A46 route from M4 Junction 18 into Bath. This report recommended safety improvements to different sections of the route. It acknowledged that in the locality of the Hartley Bends the accidents that occurred were indicative of higher speeds than road conditions would dictate, but recommended that given the short length of road involved, rather than simply apply another short change in posted speed, potentially causing confusion, driver frustration and resulting non-compliance, it would be more effective to use more overt visual methods to improve information for drivers on the hazards they are approaching in order that they drive appropriately. This recommendation was accepted and, following development of a business case, this safety scheme was included in our forward programme for implementation in early 2014. The salient proposals in the Hartley Bends locality were as follows: “4 INVESTORS An executive agency of the e Interactive vehicle activated signs (VAS) to be installed on the north and southbound approaches to Hartley Bends. These signs visually are activated by high speed and advise drivers to slow down and of the geometric hazards ahead; e Introduction of high friction surface (HFS) material that will visually highlight the road’s geometry and provide improved road holding for vehicles; e Additional hatching to provide separation between opposing traffic streams. (NB this was later deleted from the proposal after evidence emerged that the area to be hatched was consistently overrun and could present a danger to powered two wheelers (PTW); ; e The provision of yellow backing boards to augment the existing 50 mph signs (NB following discussions with the local Area of Outstanding Natural Beauty (AONB) Board these were removed in favour of the use of larger roundels to achieve the same improvement with reduced environmental impact). As previously stated, these works were programmed for early 2014 and therefore after November 2013. However, following 2 November, we took the additional precaution of providing temporary advisory 30 mph signing while we looked into accelerating future road surface renewal works, over and above the planned safety scheme. ! am pleased to say that the road resurfacing and the majority of the safety scheme were completed in May this year. The exception is the VAS signs that have been installed but not switched on, primarily due to construction issues but also to allow us to collect ‘before’ and ‘after’ speed information to determine their effectiveness and inform future decisions. In section 5(3) of your report you make reference to ‘rumble strips’. | believe you are referring to yellow bar markings as used on the approaches to roundabouts. These are not considered suitable for use on single carriageway roads as they need to be laid verge to verge in order for their extremities not. to cause a hazard to oncoming vehicles and if used on bends such as the A46 can reduce traction for vehicles. There are also adverse environmental effects such as increased noise. However, high friction surfacing (HFS) can, and has, been laid in strips primarily for increased longevity of the material and improved vehicle traction. This also results in a similar rumble impact for drivers that | believe you envisaged. | trust you consider the above satisfies points 3 and 4 of section 5 of your report. In reviewing the 2011 report | still consider that the now implemented local measures to highlight the nature of the road are logical and proactive steps, which may positively affect speeds without the need for a revised posted limit. As regards your recommendation 2 of Section 5 we proposed the following future actions: 1. A peer review by one of our other service providers not connected with this locality or the original piece of work. This is expected to be completed by the end of July 2014. pe 2. The gathering of speed data to ascertain the effectiveness of the now implemented safety scheme together with a reasonable period of accident monitoring to gauge impact, and if required, further intervention development. In this case one year would seem appropriate. Additionally we have been in contact with Avon and Somerset Police regarding their support of the imposition of a potential reduction in speed in this locality should monitoring and review of the new works indicate that it should be re-considered. The Police have indicated that they would not oppose such a proposal but confirm that it would not be routinely enforced. The Agency takes its responsibilities seriously in terms of road safety and the competing needs and requirements of our customers. | trust that on this occasion you consider the tangible improvements we have already made since November, together with the commitment to continue to assess the situation, are in accordance with your recommendations. Yours sincerely Director
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