Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0217, written 12 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 | 12 May 2014 |
|---|---|
| Reference | 2014-0217 |
| Deceased | Harold Henshall |
| Coroner | David James |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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.
Casualty investigation Manager
Casualty Reduction Team
Staffordshire County Council
Block A Wedgwood Building
Tipping Street
STAFFORD
ST16 2DH
CORONER
{am David James, assistant coroner, for the coroner area of Stoke-on-Trent and North
Staffordshire.
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 10" April 2013 | commenced an investigation into the death of Harold Gordon
Henshall, aged 86 years. The investigation concluded at the end of the inquest on 29"
April 2014. The conclusion of the inquest was Road Traffic Collision. The medical cause
of death was 1a Pulmonary thromboembolism with pulmonary infarct 1b Suspected
deep vein thrombosis II Immobility resulting from traumatic subarachnoid and epidural
haemorrhage, haemorrhagic brain contusions, fractured ribs and fractured right scapula.
CIRCUMSTANCES OF THE DEATH
At approximately 7.30pm on 17" February 2013 at A53, Church Street, Leek,
Staffordshire, adjacent to St. Edwards Church this elderly man with limited mobility that
required the use of a stick to assist with walking left St. Edwards Church. His intention
was to cross the road from the church to the nearby car park. As Mr Henshall crossed
the road from the church towards Market Square he was in collision with the front
nearside of a vehicle travelling in the Macclesfield bound lane. Mr Henshall suffered
multiple injuries and following treatment at the scene was admitted to the University
Hospital of North Staffordshire as an emergency. He remained gravely ill and died at
8.10am on 27" March 2013 at the University Hospital of North Staffordshire.
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.
a) That the level of street lighting on Church Street, Leek in the vicinity of St Edwards
Church is inadequate generally and particularly on the nearside of the Macclesfield
bound carriageway. Evidence at the inquest from local residents familiar with the
location and police evidence suggested that the street lighting was poor and patchy,
thus increasing the risk to pedestrians who choose to cross to the nearby car park
upon leaving church. It is particularly relevant to church users who are
predominantly elderly.
b) That the crossing facilities available on Church Street, Leek in the vicinity of St
Edwards Church are inadequate generally but with particular reference to church
users who are predominantly elderly. This is mindful of:-
i. the gradient of the road in both directions from the church to the nearest
pedestrian crossing facility.
ii, | The interference with visibility caused to drivers in the Macclesfield bound
direction by the gradient of the road and, particularly at night, the lights of
on-coming vehicles.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and i believe you and your
organisation] have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 4a" July 2074. |, 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 persons:-
1. Collision Investigation Unit,
Stafford Police Station
Eastgate Street
STAFFORD
—
| 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.
N
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.