Prevention of Future Deaths reports · 2014
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 report | 14 Aug 2014 |
|---|---|
| Reference | 2014-0375 |
| Deceased | Olegs Sulaimonovs |
| Coroner | Margaret Jones |
| Coroner area | Staffordshire (South) |
| 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 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
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.
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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