Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0435, written 9 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2014 |
|---|---|
| Reference | 2014-0435 |
| Deceased | Tracey Rooke |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
DAVID W. G. RIDLEY Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Senior Traffic Management Engineer Wiltshire Council — Highways County Hall Trowbridge Wiltshire BA14 8JN CORONER lam DAVID W. G. RIDLEY, Senior Coroner for Wiltshire and Swindon CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14/03/2014 | commenced an investigation into the death of Tracy Michelle ROOKE aged 43. The investigation concluded at the end of the Inquest on 06 October 2014. The conclusion of the Inquest was that Tracy sustained multiple traumatic injuries as a result of a road traffic collision that occurred on 13 March 2014 on the A3102 at Mile Elm, Wiltshire. CIRCUMSTANCES OF THE DEATH The circumstances of her death were that Tracey was travelling south along the A3102 at Mile Elm having just negotiated a left hand bend when she lost control of her vehicle which then crossed the centre of the highway before colliding with a van travelling in the opposite direction. | found that the weather conditions and in particular thick fog and her unfamiliarity with the road more tikely than not contributed to the incident and her death. CORONER’S CONCERNS During the course of the Inquest ! heard evidence from EEE whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which | believe you received a copy back in June. In that report and specifically at pages 10 & 11 of the report, a copy of which | have attached to this Regulation 28 report, he sets out a number of recommendations. | share the concerns that are raised a: his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area. | am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury of even death. | am additionally concerned having regard to the evidence that cave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 no action would be taken until | make a report with a view to the prevention of future deaths. That concerns me as if as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have power to. action and | would be grateful if you could consider the recommendations made vila indicate whether or not they are to be implemented together with a review of the Council's practice and procedure if there is no issue in relation to the recommendations as regards implementing them sooner rather than waiting for a Regulation 28 report from a Coroner after an Inquest. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04 December 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- P| Traffic Management and Road Safety Unit | 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. Dated 09 October 2014 Signature. “X> SX \ Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 Discussion and recommendations The A3102 at Mile Elm has previously been subject to a national speed restriction of 60mph for cars, reduced to 50mph on the 12 August 2013 following a national speed limit review. The road layout and condition at the collision scene is such that, in normal driving conditions, a car could travel through the bends at the maximum permitted speed without issue. It is my opinion that the 50mph restriction is correct for the road. Road signs — there is a lack of consistency in that a ‘slippery road’ warning is only given to drivers travelling south. The double bend sign (photograph 2) is in a poor condition and the position of the sign pole is such that the signs are obscured by a telegraph pole. Verge marker posts and chevron markers are ineffective due to damage / vegetation or dirt. \ Recommendation: A ‘slippery road’ warning sign should be provided to warn drivers travelling north. The double bend sign for southbound traffic should be ® replaced, with consideration for the sign pole being relocated to avoid it being obscured by the telegraph pole. Verge marker posts / chevrons should be (~? cleaned, damaged posts replaced and vegetation cut back and maintained — an alternative could be to replace the verge markers and chevrons with more modern flexible chevron posts on both approaches to the bends (example below). This could reduce the level of signage / maintenance required whilst highlighting the presence of the bends. Road markings — these are in a worn condition. The double white line system for southbound traffic does not commence until the apex of the bend (photograph 2) allowing drivers the opportunity to overtake without an appropriate view ahead. The ‘catseyes’ within the white line system are in a poor condition and ineffective. Recommendation: the road markings should be repainted, the solid white line system for southbound traffic extended to approximately 100 metres prior to the bend (this would be similar to the northbound approach). The ‘catseyes’ should be refurbished and maintained. Farm access/mud on road — on rural roads with multiple farm access points, it is inevitable that there will be a transfer of mud / debris onto the road surface. It is my opinion that the amount of mud shown in photograph 10 is excessive and unacceptable. The mud, unless cleared promptly, will be spread by traffic and extending the area of road and signage affected. Page 10 of 11 Recommendation — the Highways Authority should liaise with local farmers to identify reasonable measures that can be put in place fo.avoid any future excessive mud deposits on the road surface. ‘J Traffic Management Officer. Page 11 of 11
DAVID W. G. RIDLEY Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BB one Farm, Heddington, Calne, Wiltshire SN11 8RE 2. F Poulshot Lodge Farm, Poulshot, Devizes, Wiltshire SN10 1RQ CORONER lam DAVID W. G. RIDLEY, Senior Coroner for Wiltshire and Swindon CORONER’S LEGAL POWERS | 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14/03/2014 | commenced an investigation into the death of Tracy Michelle ROOKE aged 43. The investigation concluded at the end of the Inquest on 06 October 2014. The conclusion of the Inquest was that Tracy sustained multiple traumatic injuries as a result of a road traffic collision that occurred on 13 March 2014 on the A3102 at Mile Elm, Wiltshire. CIRCUMSTANCES OF THE DEATH The circumstances of her death were that Tracey was travelling south along the A3102 at Mile Elm having just negotiated a left hand bend when she lost control of her vehicle which then crossed the centre of the highway before colliding with a van travelling in the opposite direction. | found that the weather conditions and in particular thick fog and her unfamiliarity with the road more likely than not contributed to the incident and her death. CORONER’S CONCERNS During the course of the Inquest | had cause to hear evidence from i ; Traffic Management and Road Safety Assessment Officer with Wiltshire Police. | also had the opportunity to look at his report dated 26 June 2014. The reason for writing to each of you is that | am informed that the farmyard and land to the rear of Quobbs Farm are let to you and therefore each of you hav cess onto the A3102 from Quobbs Farm. | have enclosed with this letter page 9 of A vert which shows photographs of the entrance to Quobbs Farm that were taken at the time the police were in attendance in relation to Ms Rooke’s death. | wish to stress now that the mud on the road at this particular location played no part whatsoever in the death of Ms Rooke. The above having been said if evidence is presented to a Coroner as part of an Inquest process irrespective of it being unconnected with the circumstances of that person’s death, a Coroner can make a Regulation 28 report if he or she has concerns with a view to prevention of future deaths. | am concerned in relation to the quantity of mud visible in the photographs and also as regards the quality of signage located in such close proximity to the start of the muddied section of highway. | have dealt with deaths on Wiltshire roads that have involved farm mud on the highway and | am aware of the hazard it creates. | fully accept farmers have a livelihood to make however | would ask that you review and inform me of your practice and procedures to Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 deal with mud on the highway and as to whether or not in the light of the photographs your practices could be improved and if so how. You may also like to consider seeking advice from either the National Farmers Union or Wiltshire Council as Highways Authority. a ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04 December 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- a 2° Management and Road Safety Unit lam 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. Dated 09 October 2014 “YS Signature Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endiess Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 Other Issues Other issues a To the south of the collision scene is an entrance to Quobbs Farm. Photographs 9 and 10 were taken at this entrance on the day of the collision and show a basic sign stating ‘Caution Mud on road’, with the degree of mud on the road surface. Photograph 9 Photograph 10 Page 9 of 11
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