Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0196, written 1 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2014 |
|---|---|
| Reference | 2014-0196 |
| Deceased | Sidney Martin |
| Coroner | Robert Turnbull |
| Coroner area | North Yorkshire (West) |
| Category | Other 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.
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. The Waterway Manager, North West Waterways Canal & River Trust 2. 3. The Chief Coroner CORONER I am Robed Tumbull, senior coroner for the coroner area of North Yorkshire Western Area. 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 17th January, 2014, I commenced an investigation into the death of Ian Sidney Martin, aged 68. The investigation concluded at the end of the inquest on &h April. 2014. The conclusion of the inquest was Ian Sidney Martin died as a result of an accident. The medical cause of death was Traumatic head injury. 4 CIRCUMSTANCES OF THE DEATH Shortly before 18:30 hours on gth January, 2014, Mr Ian Sidney Martin was making his It was dark and had way from Skipton Bus Station to Tescos store to meet his wife. been raining and the ground was very wet. From the Bus Station Mr Martin used the canal bridge which leads up to Gas Street, Skipton. He fell on the wet, slippery and worn steps on the bridge sustaining a head injury from which he died in hospital later that day. At the inquest evidence was heard about other people slipping on these steps or avoiding them in wet weather realising they were dangerous. Postmortem reports and toxicology reports confirm that Mr Martin was in good health and had not been drinking at the time of the incident. 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 MAHERS OF CONCERN are as follows. — (1) The condition of the steps from the canal bridge leading to Gas Street, Skipton, presents a danger to those using the bridge. (2) The poor lighting in the area of the bridge. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR I 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 26” 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: 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. 1’ May 2014 , Robert Turnbull 7
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.
1’ J Canal& <.e River Trust Keeping people, nature & history connected 9 May 2014 Robert Turnbull Office of the Senior Coroner 21 Grammar School Lane Nodhallerton North Yorkshire DL6 1DF Dear Mr Turnbull N. Y. CORONER 15 MAY 2014 RE: Ian Sidney Martin (Deceased) — Gallows Footbridge, Skipton Further to your letter dated I May 2014 informing Canal & River Trust of the tragic death of Mr Martin on 9 January 2014 who fell down the steps at Bridge 179 (Gallows Bridge) in Skipton, I write in response to your report. I would extend our sincere condolences and sympathy to the family of Mr Martin. I would confirm that we were unaware of the incident until notified by the local newspaper some months after. The emergency services do not always notify us of incidents on the canals that the Canal & River Trust (the Trust) manages. As soon as we were made aware we undertook an investigation visit to the bridge. We have given your report very careful thought, and can confirm that public safety is the highest priority for the Trust. We note from the Regulation 28 Report that on the date of the accident in January it had been raining and that being evening it would have been dark. The report states that the steps were wet, slippery and worn. The Trust’s Health and Safety Advisor and I have both separately inspected the steps and are able to confirm that the step surface is rough in finish giving no indication of being likely to be slippery when wet. The surface of the steps is good with little sign of wear despite the footbridge taking very heavy footfall being located adjacent to the bus station into Skipton, There is a handrail on one side of the steps. Photographs that were taken by the Safety Advisor at the time of his visit are attached for your information. North West Waterways Canal & River Trust Waterside House Waterside Drive Wigan WN3 5AZ T 0303 040 4040 E enquiries.northwestcanalrivertrust.org.uk www.canalrivertrust.org.uk Patron: H.R.H. The Prince of Wales. Canal & River Trust, a charitable company limited by guarantee registered in England and Wales with company number 7807276 and registered charity number 1146792, registered office address First Floor North, Station House, 500 Elder Gate, Milton Keynes MKQ 1 BB S.-) 3
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