Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0417, written 24 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2014 |
|---|---|
| Reference | 2014-0417 |
| Coroner area | Cheshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Highways Agency 1 CORONER I am Alan Gordon MOORE Assistant Coroner for the coroner area of Cheshire. 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 10 January 2014 I commenced an investigation into the death of Jake Anthony JOHNSON (age 22). The investigation concluded at the end of the inquest on 10 September 2014. The conclusion of the inquest was Accident. The medical cause of death was traumatic brain injury. CIRCUMSTANCES OF THE DEATH 4 Jake suffered from autistic spectrum disorder with symptoms suggestive of Asperger’s syndrome. This condition led him to establish various lifestyle routines. One such routine was that Jake regularly went off on long walks, often alone. On the afternoon of 6 January 2014 he went walking alone. He told his family that he was planning to explore a new walking route but he did not say where he would be going. At approximately 5.45 pm he was seen to run across the Manchester-bound carriageway of the M56 close to marker post 43/9 near Junction 12. He was struck by a lorry. He sustained injuries, including a traumatic brain injury which proved fatal. Jake had apparently gained access to the M56 via a set of steps near a culvert / bridge support structure below the motorway. The steps were not closed off and were easily accessible. A representative of the Highways Agency ( gave evidence at the inquest. He stated that the original purpose of the steps was to permit access by engineers, not the general public. He added that the steps are now redundant, the engineer access no longer being required. went on to say that there is long standing damage / deterioration to parts of the timber fencing along this section of the motorway boundary close to the M56. also stated that there are no signs in place warning the public of danger due to the close proximity of the motorway. I heard evidence from Jake’s family that there is a children’s playground in reasonably close proximity to the area in question. 1 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 steps afford open access to the M56 motorway (although their original design purpose is seemingly now redundant); 2. Part of the boundary fencing in the vicinity of the steps is damaged or in a state of disrepair; 3. There are no signs in place warning the public of danger, due to the proximity of the motorway; 4. I am told that there is a children’s play area in the vicinity. 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 19 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 (Jake’s mother), who is an Interested Person. I have also sent it to the Highways Department at Halton Borough Council who may find it useful or of interest. 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 24 September 2014 A G MOORE Assistant Coroner for Cheshire 2
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