Prevention of Future Deaths reports · 2014

Prevention of Future Deaths report 2014-0415

Regulation 28 report to prevent future deaths, reference 2014-0415, written 22 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report22 Sep 2014
Reference2014-0415
Coroner areaTeesside
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 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  A-one+ 
2. 
3.  Cleveland Police Roads Policing Unit 

1 

CORONER 

I am Clare Bailey, acting senior coroner, for the coroner area of Teesside 

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 10th May 2012 I commenced an investigation into the death of Jerome Antoine Marie 
GONNET, age 53 years. The investigation concluded at the end of the inquest on 28th 
August 2014. The conclusion of the inquest was ACCIDENTAL DEATH.  The medical 
cause of death was Ia Multiple Injuries. 

4 

CIRCUMSTANCES OF THE DEATH 

On the 2nd May 2012 a female drove the wrong way along the A66 eastbound 
carriageway near Long Newton, Stockton on Tees.  She collided head on with the car in 
which the deceased was a passenger. 

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) It is unclear in advance of approaching the junction that the slip road upon which the 
female drove is ‘no entry’ slip road. There is no information in this regard on the road 
signs surrounding the junction. 
(2) At present there are temporary large ‘no entry’ signs at the exit of the slip road 
junction which have, on occasions, been knocked over and subsequently rendered 
unnoticeable.   
(3) It has been brought to the Coroners attention that since Mr Gonnet’s passing a 
further two drivers have driven down the exit slip road, in the same manner as the 
female driver who caused Mr Gonnet’s passing. 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6 

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.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 17th November 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 
 and Cleveland Police Roads Policing Unit. 
Persons 

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 

22nd September 2014                                   C Bailey, Acting Senior Coroner 

2

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 A One (PDF)
A-onet+

Valley House Valley Street North Darlington DL1 1TJ
Tel +44 (0)1325 389 991 Fax +44 (0)1325 385 777
Email enquiriles@aone.uk.com Web www.aone.uk.com

F.A.O. C Bailey Integrated Highway Services
Acting Senior Coroner for Teesside A HALCROW/ COLAS / COSTAIN COMPANY

The Coroners Service
Middlesbrough Town Hall
Albert Road
Middlesbrough

TS1 1QJ

16 October 2014 Your ref

Dear Sir

A66 Elton Interchange, Stockton-on-Tees
Jerome Antoine Marie Gonnet

I write on behalf of A-one+ Integrated Highway Services (“A-one+”) in response to your letter
of 22 September 2014 and the attached Regulation 28 Report to Prevent Future Deaths

The Report relates to a road traffic collision that took place on the A66 eastbound carriageway in
the vicinity of Long Newton, to the west of Stockton-on-Tees after a driver travelling in the
wrong direction entered the A66 eastbound carriageway from the A66 Elton Interchange,
Hartburn.

Section 5 of the Report raises a number of matters of concern in relation to this interchange.
Before addressing each of these matters in turn, I consider that it would be helpful to provide
some background information on the way in which A-one+ operates, and how our
responsibilities interact with those of other organisations.

Background

The Highways Agency is responsible for the management and maintenance of motorways and
trunk roads in England. The network of roads which the Highways Agency is responsible for is
divided into six regions, which are subdivided into 13 operational areas. Each of these areas is
maintained on a day to day basis by a Contractor on behalf of the Agency. A-one+ acts as the
Managing Agent Contractor for the North East England region. A-one+’s role is to maintain and
carry out minor improvements to the road network within its areas, with overall responsibility
retained by the Highways Agency.

Local highway authorities are responsible for the management of maintenance of local roads,
which are outside of the Highways Agency’s remit.

I have reviewed the matters of concern which you have raised, with input from the Highways
Agency, and set out our response below. However, as some of the roads involved form part of
the local, rather than national, road network, the local highway authority, Stockton-on-Tees
Borough Council, may be able to provide further clarification and assistance.

Response to matters of concern

1. It is unclear in advance of approaching the junction that the slip road is “no entry”, with
no information in this regard on the road signs surrounding the junction

The Highways Agency is responsible for the A66 trunk road in the vicinity of Elton
Interchange, including the main through carriageways from highway boundary to highway
boundary. The Highways Agency is also responsible for the entry and exit slip- roads from
and to the locations where they meet the edges of the circulatory carriageways of the
roundabouts located to the north and south of the over-bridge.

However, the local roads, including all other arms of these roundabouts, the over-bridge and
the roundabouts themselves, are the responsibility of the local highway authority, Stockton-
on-Tees Borough Council. This means that responsibility for the installation and maintenance
of road signs leading up to the slip road taken by the female driver on 2 May 2012 rests with
Stockton-on-Tees Borough Council. This responsibility includes placing appropriate advance
direction signs on the approach to the interchange to ensure that motorists are aware of the
road’s layout and direction of traffic.

As the provision of these signs is outside of the responsibility of the Highways Agency and
A-onet, I am unable to provide any further information in relation to this concern. However,
Stockton-on-Tees Borough Council may be able to provide further assistance.

2. Temporary ‘No entry’ signs at the end of the exit of the slip road are occasionally
knocked down, rendering them unnoticeable.

Permanent illuminated ‘No entry’ signs have been in place on both sides of this slip-road for
many years (and were in place at the time of the incident), as required by the relevant
regulations, (Chapter 3 of the Traffic Signs Manual) which gives guidance on the size and
mounting of such signs as follows:

‘The ‘no entry’ sign to diagram 616 (of the Traffic Signs Regulations and General
Directions) should be placed on each side of a one-way road at the point where entry is
prohibited. When the road to which the signs apply forms a junction with the side of
another road, the signs should be sited in line with the backline of the major road. The
signs must be placed so that one is clearly visible at all times to traffic approaching from
any permitted direction; this might require a sign to be angled slightly.’

Appendix A of this document also indicates the recommended size of such signs, which relate
to the speed of traffic on the relevant road (in this case the roundabout). On the slip road in
question, 600mm diameter signs have been installed, which are suitable for traffic speeds of
up to 30mph.

In response to the road traffic collision of 2 May 2012, and at Cleveland Police’s request,
supplementary ‘No entry’ signs, which are in addition to those mandated under statutory
requirements, have been installed. However, one of these signs has been placed in a block
paved area of carriageway and this sign is at times knocked over by passing vehicles, as
indicated by the Report.

The block paved area at this location was installed to address problems associated with the
lower than normal bridge deck level at Elton Interchange when the interchange was originally
constructed. When abnormally tall and wide or long loads are being moved along the A66
eastbound carriageway, these vehicles are required to divert from the main carriageway of the
A66 over the extents of this interchange. Some of these vehicles, under escort, need to pass
through the block paved area and travel in an anticlockwise direction around the roundabout’s
circulatory carriageway, in order to rejoin the A66.

Consequently, it is not possible to install permanent traffic signs in this area. To address this
the supplementary sign has been installed on a temporary sign-frame. This sign is regularly
inspected by A-one+ on behalf of the Highways Agency and any damage is rectified as soon
as possible.

. Two other incidents have been reported involving drivers travelling in the wrong
direction on this exit slip road.

Both A-one+ and the Highways Agency have been made aware of one of these incidents by
Cleveland Police. I can advise that an investigation has been undertaken to identify options
for improvement at this interchange. The improvements which are being considered include
installing demountable bollards or marker posts in the block paved area and installing
additional road markings.

Any proposed improvements are subject to securing appropriate funding. The Highways
Agency, allocates its limited funds to improvement schemes by prioritising funding for
schemes which are assessed to have the greatest potential safety benefits.

A proposal for these works will be submitted for funding during the next bidding round for
improvement schemes. If successful, it is likely that these improvements will be implemented
in 2015. In the meantime, the supplementary signs will continue to be regularly inspected and
maintained.

I trust that this information is of assistance. If you require any further information or
clarification please let me know.

Yours faithfully

General Manager

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