Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0060, written 18 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Feb 2015 |
|---|---|
| Reference | 2015-0060 |
| Deceased | Keri Holdsworth |
| Coroner | C W M Donnelly |
| Coroner area | Hartlepool |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways Agency 2. Hartlepool Borough Council 1 | CORONER | am C.W.M.Donnelly, senior coroner for the coroner area of Hartlepool, & assistant coroner for the area of Teesside 2 | 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. 3 | INVESTIGATION and INQUEST On 14" June 2014 | commenced an investigation into the death of Keri Victoria Holdsworth. The investigation concluded at the end of the inquest on 16" February 2015. The conclusion of the inquest was accidental death, following a road traffic crash on the 13” June 2014 wherein the deceased sustained fatal injuries. 4 | CIRCUMSTANCES OF THE DEATH On the 13" June 2014 the deceased was involved in a road traffic crash at the junction of the A19 road and the road from Dalton Piercy village. She had been travelling northwards in the offside lane, and probably braked suddenly as a van in the central reservation was about to pull out and join the northbound carriageway. She lost control of her vehicle, crossed over the junction and collided almost head on with a southbound vehicle travelling in the offside southbound lane. 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) This is the latest in several serious incidents at this junction, three of which have been fatal within the last five years. All of the fatal incidents have involved vehicles either turning right at this junction to join the northbound A19, or turning right from the northbound into the Dalton Piercy junction. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. The specific action is the closure of the junction to traffic wishing to turn right. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 April 205. |, 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 senta ue of a report to the Chief Coroner and to the following Interested Person - - who may find it useful or of interest. 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. 18 February 2015
2 responses 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.
REAR and Neighbourhoods Department Civic Centre Hartlepool TS24 8AY Assistant Director (Neighbourhoods) — _| 28 APR 2015 DX 60669 Hartlepool-1 Email: Our Ref | HARTLEPOOL BOROUGH COUNCIL Your Ref 20" April 2015 C WM Donnelly Senior Coroner for Hartlepool The Coroners Service Town Hall Albert Road Middlesbrough TS1 2QJ Dear Mr Donnelly INQUEST INTO THE DEATH OF THE LATE KERI VICTORIA HOLDSWORTH Thank you for your letter dated the 17" April, 2015. My apologies if there has been any misunderstanding. The position is that this stretch of road network falls under the jurisdiction of Highways England (formerly known as The Highways Agency). All responsibility for speed restrictions, layout design and potential scheme improvements lies with them and not with ourselves at Hartlepool Borough Council. We are however in dialogue with Highways England and will assist in any associated external, third party issues that may arise through design briefs etc that are required. | contacted Highways England (Highways Agency) upon receipt of your last 141° correspondence and asked them as lead body to respond on behalf of both ourselves and the Highways Agency, explaining the position in respect of potential studies being carried out to improve the safety of the network. All funding responsibility for improvements to the A19 network lie with Highways England and therefore deems them to be the project sponsor and instigator of any improvement scheme(s). 0420 C W M Donnelly, The Coroners Service, Town Hall, Albert Road, Middlesbrough.docx -2- | hope this clarifies the position, and if | can be of any further assistance, please do not EN oF alternatively e-mail at —_— to contact me on Yours sincerely P| ASSISTANT DIRECTOR (NEIGHBOURHOODS) oners Service, Town Hall, Albert Road, Middlesbrough.docx o420C WM Donnelly, The Cor
|| HIGHWAYS AGENCY Safe roads, reliable journeys, informed travellers Our ref: Your ref: Asset Delivery Manager (Acting) 3 SOUTH Lateral Mr C W M Donnelly 8 City Walk Senior Coroner for Hartlepool Leeds LS11 9AT The Coroners Service Town Hall Direct Line: F Albert Road Middlesbrough 3 March 2015 TS1 2QJ Dear Sir REGULATION 28 REPORT INQUEST INTO THE DEATH OF THE LATE KERI VICTORIA HOLDSWORTH | refer to your letter of 28 February 2015 enclosing your Regulation 28 Report following your inquest into the death of Keri Holdsworth on 13 June 2014. You have requested in your report that the Highways Agency close the A19 Dalton Piercy junction to traffic wishing to turn right, and report to you what action the Highways Agency intends to take in this respect. Prior to the above accident the Highways Agency undertook a Route Safety Action Plan to identify locations on the A19 that display a poor accident record. This highlighted the junctions at Elwick, a short distance north of the Dalton Piercy junction. Study work was initiated to look at what improvements could be made to the junction including the provision of a bridge and the closure of the central reserve gaps. Following the above accident the scope of this study was extended to consider whether the provision of a bridge at Elwick could facilitate the closure of some or all of the central reserve gaps, including the Dalton Piercy junction, along the section of the A19 between the A689 and A179 junctions. Hartlepool Borough Council are a partner in this study. The study is due to report in August 2015. Closure of any of the gaps, including the Dalton Piercy junction will be dependent on the outcome of the study which will consider whether there are viable alternative routes for right turning traffic and whether there is a strong business case for doing so. Construction of any subsequent scheme would be subject to the availability of funds. Yours faithfull NDD Yorks & NE Email: Dalton Piercy Coroners Letter.docx Page 1 of 1 ae hoy, “ N s Vie é >! INVESTORS Anexecutive agency of the AA Wg IN PEOPLE Department for Transport
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