Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0020, written 23 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jan 2015 |
|---|---|
| Reference | 2015-0020 |
| Deceased | Hilary Moock and Janice Taylor |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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: Louise Goldsmith, Leader of West Sussex County Council, County Hall. Chichester, West Sussex 1 CORONER I am Penelope Anna Schofield, Senior Coroner, for the Coroner area of West Sussex 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 17th December 2014 I concluded the inquest into the deaths of MRS HILIARY MOOCK (aged 83) AND MRS JANICE TAYLOR (aged 74 yrs), who both died on 28th September 2013. I determined that Mrs Moock died as a result of Multiple skeletal injuries including severe head and chest injuries and Mrs Taylor died as a result of Multiple skeletal injuries including severe chest injuries and a ruptured heart and that their deaths were the result of a Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH 1. On Saturday 28th September 2013, at approximately 10.45pm was driving his Volkswagen Golf motor car northbound along the A285 from Chichester to the home address of his friends, They had all been to the Theatre in Chichester. and Mrs Moock were guests of and Mrs Taylor and had been planning to stay with them and Mrs Taylor namely over the weekend of 28th and 29th September 2013 seat, in the rear nearside seat. was at the time accompanied by Mrs Janice Taylor, who was sat in the front passenger , who was sat in the rear offside seat, and Mrs Hilary Moock who was sat and other guests had gone is a separate car. 2. 3. 4. Travelling south on the same road and at the same time was who was driving his Honda Civic motor car. The evidence he gave at the Inquest was that he was driving at between 55 – 60 miles. The speed limit for this road was the national speed limit of 60 miles per hour. admitted that he had consumed at least 1.5 pints of lager. A road side breath test showed that his alcohol reading in breath was 21 micrograms which was within the legal limit of 35 micrograms of breath. 5. As approached the entrance to St Mary’s Farm and Benges cottages it appears that there may have been some confusion by the occupants in the car as to exactly where the entrance was. was relying on Mrs Taylor giving him instructions. The entrance is difficult to negotiate as it is close to the brow of a hill, there is no lighting and the entrance is straight onto unmade road which is full of pot holes. approached the entrance he slowed right down and then turned right It appears that as and travelled across the southbound lane. As he did so he was impacted broadside (in a T-bone configuration) by car which was travelling through the junction. 6. 7. Tragically both Mrs Moock and Mrs Taylor sustained fatal injuries from the collision. 5981872.1 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 A285 is an ancient rural road and it does not meet the design standards of a modern road. It is noted that this road features in the list of persistently higher risk roads under the EuroRap fatal and serious collisions per kilometre travelled analysis. (2) The location of this accident is in a dark unlit area and there is no clear indication that there is an entrance into St Mary’s Farm and Benges Cottages. This is a difficult turn to make from the Northerly approach as the line of sight to the brow of the hill is only 90 metres. (3) There is only limited amount of asphalt at the entrance into St Mary’s Farm and Benges Cottages of some 2 metres. The road then becomes “unmade” and uneven with several large potholes. It appeared from the evidence that because of this drivers are somewhat cautious when driving into the road. (4) This hesitation could cause drivers to slow down their approach into the road and therefore put them at risk from vehicles travelling in the opposite direction. I consider that there is a risk that future deaths may occur in similar circumstances and action should be taken to reduce the risk 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 19th March 2015. 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: 1. 2. 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 DATE: 23rd January 2015 SIGNED: Penelope Schofield, Senior Coroner West Sussex 1 5981872.1
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.
Leader of the Council www.westsussex.gov.uk Cabinet Office County Hall West Street Chichester West Sussex PO19 1RQ 17 March 2015 Response of West Sussex County Council to Report to Prevent Future Deaths issued by Penelope Schofield, Senior Coroner dated 22 January 2015 following an inquest into the death of Hilary Moock and Janice Taylor. 1. The A285 does feature on the EuroRap list of persistently high risk routes under the EuroRap fatal and serious collisions per kilometre travelled analysis. However the specific location of this incident does not express a high collision rate. In the five years to December 2014 there have been three reported injury collisions including that of the 28th September 2013. The other two collisions resulted in slight injuries. West Sussex County Council’s current criterion for investigating collision cluster sites for possible remedial measures is eight reported injury collisions in five years or five reported injury collisions in three years. The EuroRap listing is not therefore a useful reference point for an assessment of intervention need for the specific location of this incident. 2. The route is a rural road in the heart of the South Downs National Park and as such, in common with other rural roads, is unlit. The start of the entrance is indicated by a bridleway direction sign (to diagram No 2610 Traffic Signs Regulations and General Directions 2002) sited at its junction with the A285, which serves as a marker. St Mary’s Farm, Benges and Benges Cottages are private destinations and it would be expected that visitors with private vehicular right of access would be familiar with the location of the entrance. Lighting for the route would be both disproportionate to benefit and would be contrary to light pollution minimisation within such a rural setting. Specific lighting for such a junction would be a distraction rather than a benefit to drivers. Visibility is limited by the topography (a hill crest slightly north of “Benges”) which makes turning manoeuvres on this section of road slightly more difficult to negotiate than on a road designed to modern standards, but not exceptionally so. The visibility is not reduced below the stopping distances given in the Highway Code for 60mph. Traffic speed surveys have recently been undertaken using automatic traffic counters that recorded data between the 20th January 2015 and the 4 February 2015. The results show that the average speed of southbound vehicles as they crest the hill and approach the junction is 43mph with an 85th percentile speed of 51mph. Within this range a southbound vehicle will cover the 90m between the hill crest and the junction in 4.6 to 3.9 seconds. This assumes that the approaching driver makes no reactive adjustments on seeing a turning vehicle and maintains their speed. Our own on site field tests undertaken in daylight and darkness showed that from a standing start, handbrake on, wheels aligned straight and proceeding cautiously, the right turn manoeuvre was completed in between 3 and 3.5 seconds (to fully clear the southbound lane and enter the bridleway). In daylight it was possible to complete the turn without causing a southbound vehicle to adjust its speed if the manoeuvre was started before there was a southbound vehicle in sight. If a vehicle was in sight then the turn was not executed. At night it was far easier to judge the presence of oncoming vehicles as the glow from their headlights was apparent a significant time before they crested the rise. We conclude that the 90m forward visibility for a right turning driver is adequate for drivers exercising proper care and attention. 3. The asphalt surface of the A285 only extends as far as its carriageway width or to the extent of its highway boundary at the junctions of unmade tracks and entrances, in this case 2 metres beyond the carriageway edge line at the junction of the bridleway. Our own investigation in October 2013 considered the condition of the access track to St Mary’s Farm and Benges Cottages and whether this had been a causative factor in the collision. Evidence given at the inquest in relation to the behaviour and actions of the driver of the vehicle executing the turn and the range of factors that may have affected his judgment on this specific occasion will be significant in terms of causation and will have been taken into account. It is not considered that the change in surface would of itself have been a significant factor outside those additional and particular factors pertinent to the incident. There is no public right of way by motor vehicles along the bridleway; such use is restricted to drivers with a private right of access. Responsibility for the maintenance of the surface for vehicular use falls to the private users. These drivers will be familiar with the location, its condition and its intersection with the main highway. We do not consider it likely that such drivers will exhibit excessive caution at this location due to the change in surface. It would seem reasonable to conclude that regular motor-vehicle users of the track are those best placed to make a decision on the suitable condition required for safe access to and from the main highway. At a site visit one year on from our original investigation it appeared that the track was in a similar condition to that on the date of the fatal collision. It could be surmised that regular users with private vehicular rights do not consider that its condition hinders motor vehicle access to the degree that it requires them to undertake regular and on- going maintenance. The Authority does not consider that access to or from the main carriageway requires such maintenance given the history of incidents at this point. 4. There is no duty on West Sussex County Council as the Highway Authority to maintain the bridleway beyond that standard required for its publicly permitted use. More, the construction of an asphalt hard surface may go beyond the power to carry out works to improve highways given under Section 62 (2) of the Highways Act 1980 as this should be determined by the public use attaching to the route. Given this and the other considerations above the County Council does not consider there to be any grounds to carry out any works to extend the area of asphalt surface further into the bridleway. The landowner may seek planning permission to make improvements to improve the quality of the surface so as to ease vehicular use and the County Council would not unreasonably object to such permission, subject to normal planning processes, should they wish to do so.
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