Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0332, written 15 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 | 15 Jul 2014 |
|---|---|
| Reference | 2014-0332 |
| Deceased | Ming Cheung |
| Coroner | Sean McGovern |
| Coroner area | Coventry |
| 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.
REGULATION 28: draft 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: Chief Executive – Tesco PLC Tesco PLC New Tesco House Delamare Road, Cheshunt, Hertfordshire, England EN8 9SL customer.service@tesco.co.uk 1 CORONER I am S McGovern, Senior Coroner, for the coroner area of Coventry 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 I opened an investigation on 28 January 2014 into the death of Ming Tsung CHEUNG, late of 176 Melbourne Road, Coventry. I concluded the inquest on 15 July 2014 and returned a conclusion that her death was road traffic incident. 4 CIRCUMSTANCES OF THE DEATH Miss Cheung was a student at Warwick University. She crossed Lynchgate Road, Coventry and was struck and killed by a lorry. 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. – I heard evidence that the point where Miss Cheung crossed the road was used by many pedestrians and had developed into an unofficial crossing point. Anecdotally there was some evidence of near-misses in terms of pedestrians being hit by vehicles. I heard evidence that a large Tesco sign obscured the view of Miss Cheung and the lorry driver. It may be that removal of the bottom wooden panels of the sign would be sufficient although I await to hear your response. 1 Foy your information I also enclose a copy of a regulation report addressed to Coventry City Council concerning the same incident. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 9 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (a) Brindle & Yam solicitors for the family of Miss Cheung 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 15th July 2014 [ Senior Coroner S McGovern 2 3
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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.
NetworkRail Mr MR Rose Kings Place HM Senior Coroner 90 York Way Office of Her Majesty's Coroner London The Western District of Somersetshire N1 SAG Blackbrook Gate Blackbrook Park Avenue Taunton Somerset TAI 2PG 22 August 2014 Your Ref: MRR/sp Dear Mr Rose Anthony Shane Ponting deceased Regulation 28: Report to Prevent Future Deaths Thank you for your letter dated 8" July 2014 enclosing the Regulation 28 Report relating to the tragic death of Anthony Shane Ponting at Springfield Road Pedestrian Crossing, Somerset. At paragraph § of the Report, you refer to the ORR report dated 13 August 2013 saying that it “revealed several matters which although in no way responsible for this death could cause a potential risk to other users, namely.- (i) Reduced sighting line caused by track side vegetation growth for pedestrians crossing from the upside to up trains and on the downside for both up and down trains at the SHI [Stop, Look, Listen (SLL)] sign (ii) The SHI [SLL] boards should have been positioned 3 metres from the line. (ii) Tripping hazards on the crossing surface” Your recommendations in paragraph 6 of the Report recognise that the vegetation was cut back shortly after the accident, but confirmed that items (ii) and (jii) should be attended to if not already dealt with and that items (i) and (iii) are looked at regularly in the future. The vegetation growth was cut back during the first week of August 2013. In terms of managing the vegetation going forward, this has been and will continue to be routinely checked at six-monthly inspections. Most recently, those inspections were conducted on i6® Network Rail January 2014 and 26" June 2014 where the sighting line was deemed to be satisfactory. The next inspection of the crossing is scheduled to take place in the first week of December 2014. Concern S(ii) regarding the SLL signs has been addressed. On 8" August 2014, the SLL sign on the on the down line was moved from 4.9 meters to 3 meters as recommended in your report. The SLL sign on the up side remains at 3.4 meters from the track. There is some troughing at the 3 meter point which makes this sign more difficult to move, but the current location of the sign is appropriate and fit for purpose. As we understand it the ORR report focussed on the inadequacy of the SLL sign on the down line. The signage will continue to be assessed as part of the routine inspections, the next of which is scheduled for the first week of December 2014. Concern 5(iii) has been addressed. In early March 2014 and as part of more extensive track works in the area, the surface system was completely renewed in modern rubber panels free of tripping hazards. Again the surface is checked for condition at each six-monthly inspection regime, the next one being in the first week of December 2014. | would take this opportunity to highlight Network Rail’s commitment to safety. It is a core Network Rail value and we are committed to making sure everyone gets home safely every day be it employees, contractors or members of the public. We have invested much time, money and effort into reducing the risks inherent in level crossings and our work over the past four years has reduced that risk by 31%. This includes closures, improved engineering risk controls and targeted action to influence user behaviour and we will continue our work to improve safety at level crossings having been entrusted with significant funds over the next five years to do so. | hope that the response provides you with adequate information and assurance that the issues you identified are taken seriously and have been addressed. If you would like any further clarification, please do not hesitate to contact me. Yours sincerely Mark Carne Chief Executive
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