Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0328, written 9 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2014 |
|---|---|
| Reference | 2014-0328 |
| Deceased | Georgina Taylor |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| 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.
REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Department of Transport
2. The Highways Agency, Piccadilly Gate, Manchester
3. Police Sergeant [A
4. Family of the deceased
CORONER
tam the Senior Coroner for the coroner area of Manchester North
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and regulations 28
and 29 of the Coroners (Investigations) Regulations 2013
INVESTIGATION and INQUEST
On the 31° January 2014 | commenced an investigation into the death of Georgina Lauren Taylor whose death
was reported to my office on the 27" january 2014. The cause of death following Post Mortem Examination
was that of 1a) Multi-organ injury. | finalised the Inquest on the 25" June 2014 with a conclusion of ‘Road
Traffic Collision’.
CIRCUMSTANCES OF DEATH
A combination of inexperience and excessive speed contributed to the driver losing control of a motor vehicle
which was being driven in lane 2 of 2 on the A627(M) whereupon the vehicle rotated anti-clockwise through
90 degrees as it crossed lane 1 and mounted the embankment to the nearside where the rear offside of the
vehicle collided with a tree which impact resulted in the vehicle rolling up onto the tree and rotating
clockwise through 180 Degrees before coming to rest.
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:-
4. The section of the A627(M) where this incident occurred forms the south bank carriageway of the
motorway, approaching Junction 1 at Chadderton, Oldham. The A627(M) is a two lane, dual
carriageway and is subject to motorway regulations including the national (70 miles per hour) speed
restriction.
2. The introduction of the interim requirements for road restraint systems in 2002 identified that alt
trees with a girth exceeding 500mm (or several closely spaced trees) located within a distance of 4.5m
from the paved carriageway require protection. The re-issued requirements in 2004 identified that
trees above 300mm in girth should be protected by a suitable vehicle restraint system.
3. Current design standard TD19/06 includes a site specific risk process where topographical features,
together with adjacent sources of risk are reviewed in order to identify the most appropriate restraint
facility and containment levels and that in relation to the presence of trees adjacent to the nearside
verge and protection requirements, it is unclear as to when these germinated and it is likely that they
are all ‘self-seeded’ with the larger specimens being over 10 years old. Whilst the vehicle restraint
systems in place comply with identified requirements at the time of the construction of the route,
there are no current requirements to inspect soft estate as it develops in terms of assessing
protection requirements. The application of more recent design standards would have required some
of the trees at this location to be protected {as well as the lighting columns) or removed within the
4.5m threshold.
4. EER» evidence stated that ‘it might be prudent to remove some of the trees and that the issue
of a Regulation 28 report would generate a review of the area in question’.
ACTION SHOULD BE TAKEN
Department of Transport in conjunction with The Highways Agency to consider the implications to ameliorate
and / or negate the consequences arising from the impact of motor vehicles with road lighting columns and
trees.
_——_-__+__
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely an September
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.
COPIES and PUBLICATION
1. {have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely
Department of Transport
The Highways Agency, Piccadilly Gate, Manchester
Police Sergeant
Family of the deceased
The Chief Coroner
yop YN
tam 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 from. 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 coronerat the time of your response, about the release or the publication of your
response by the Chief Coroner.
Date: 09/07/2014 Signed:
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.