Prevention of Future Deaths reports · 2014

Olegs Sulaimonovs

Regulation 28 report to prevent future deaths, reference 2014-0375, written 14 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Aug 2014
Reference2014-0375
DeceasedOlegs Sulaimonovs
CoronerMargaret Jones
Coroner areaStaffordshire (South)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 
2. 

 Billington Farm, Billington Bank, Stafford ST18 9DQ 

& 
Staffordshire Police 

, Collision Investigation Unit, 

3.  Highways Department, Staffordshire County Council 
4.  The Chief Coroner 

1  CORONER 

I am Mrs Margaret Joy Jones Assistant coroner for the coroner area of Staffordshire 
South 

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 13 March 2014 I commenced an investigation into the death of OLEGS 
SULAIMONOVS, 34 years. The investigation concluded at the end of the inquest 
on 14 August 2014. The conclusion of the inquest was as a result of an accident 
having sustained a fracture of first cervical vertebra. 

4  CIRCUMSTANCES OF THE DEATH 

The deceased was a Latvian National who had travelled to the UK on 6th March 
2014 to work on a Fruit farm situated on the A518 and known as Dearsden Farm, 
Billington Bank, Stafford.  During the season this and other neighbouring farms 
house an estimated 2000 migrant workers accommodated in caravans. 
The farms are situated some miles outside of Stafford Town Centre on a very dark 
unlit single carriageway A road which is subject to a 60mph speed limit.  For the 
majority there is no footpath and public transport is very limited at night.  Police have 
received a number of complaints about pedestrians walking in the road which is 
particular hazardous during the hours of darkness. 
At around 01.10hrs on the 9 March 2014 the deceased was walking in the 
carriageway towards Stafford.  He was wearing dark clothing and was struck from 
behind by a vehicle travelling in the same direction.  The deceased had consumed a 
considerable amount of alcohol. 
The Police evidence was that this is a dangerous stretch of road.  They had 
previously produced road safety leaflets to be distributed to migrant workers which 
had been printed in various languages but the circulation was limited and that the 
migrant workers would benefit from advice as to the dangerous nature of that road 
and encouragement to wear reflective clothing. It was probably unrealistic to expect 
the local authority to provide a footpath and lighting but they should be made aware 
of the problem. 

 
 
 
 
 
 
 
 
 
 
 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.  The lack of information given to the migrant population temporally resident in 

the area with regard to the nature of the road. 

2.  The lack of supply/encouragement to wear reflective clothing. 
3.  The absence of a footpath and suitable lighting. 
4.  The lack of speed restrictions in an apparently highly populated area.  

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 2nd October 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 Staffordshire Police, Staffordshire County Council Highways Department.  

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 

Margaret J Jones 
HM Assistant Coroner 
Staffordshire (South) 

14 August 2014

Responses

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.

Response from T.w. Busby Son (PDF)
T.W.BUSBY & SON
Dearnsdale Farm
Haughton
Stafford

$118 9DH

Margaret Jones

HM Assistant Coroner ( Staffordshire South)

Coroner's Office

No1 Staffordshire Place

Stafford

$T16 2LP

‘our

October 18 2014

Dear Madam,

Re: Olegs Sulaimonovs (Deceased)

Regarding the above, preventative measures to be taken to restrict the amount of future deaths taking
in to account of Olegs Sulaimonovs killed on 6" March 2014.

As an employer it is our duty of care of our staff during working hours but as you can appreciate we
cannot enforce restrictions on their movements during non- working hours or after a work shift this is
against their rights of movement and freedom to live and enjoy their stay at our farm.

But we will make available the supply of reflective vests in their accommodation and part of our terms
of employment and they will be recommended to wear them at night in walking on the A518 and include
this in our induction, recruitment process going forward for 2015 as all our seasonal staff are departing
now.

To note, you stated lack of information provided on the area with regard to the nature of the road... we
always induct our staff on the use of public transport and avoid walking the A518 road due to the speed
of traffic. Asa resident (TW Busby & Son) and current drivers we have found driving along this A518
and the amount fatalities vehicles drive fast along the A518 and WARNING signs would be appreciated
for Pedestrians crossing between Billington and Bury Ring Bank as there are home owners either side
of these banks.

Lastly, translated documentation proved by the police is for drivers but not for pedestrians and this is
not relevant to a lot of farms as most staff due not have cars but dependent on transport we supply and

1

the public transport. So further documentation would be appreciated by the Community Police and we
will address accordingly. Thank you.

Yours faithfully,

ON BEHALF OF TW BUSBY & SON

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