Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0144, written 17 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2015 |
|---|---|
| Reference | 2015-0144 |
| Deceased | Patrick Sturtivant |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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: Secretary of State for Transport, Department for Transport, Great Minster House, 33 Horseferry Road, London SW1P 4DR Mr Simon Thurley, Chief Executive English Heritage, 1 Waterhouse Square, 138-142 Holborn, London EC1N 2ST HE General Manager Wiltshire Landscape National Trust, Avebury Manor, High Street, Avebury, Wiltshire SN8 1RF Mr Tim Parker, Chairman of the National Trust, Central Office, Heelis, Kemble Drive, Swindon SN2 2NA EE en Corporate Director, Wiltshire Council, County Hall, Bythesea Road, 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 01 September 2014 | commenced an investigation into the death of Patrick Derek Sturtivant, aged 37. The Inquest was opened on 08 September 2014 and the final hearing was originally scheduled for 06 February 2015 however this regrettably had to be adjourned due to a breakdown in communication as regards the availability of a witness. The investigation however was concluded on Wednesday 15 April 2015. The conclusion of the Inquest was that Patrick, known to his family as Pat, had died as the result of a traumatic brain injury sustained in a road traffic collision. My formal conclusion on the Record of Inquest as to death was “Road Traffic Collision”. The collision itself occurred on 29 August 2014 with Pat passing away the following day (30 August 2014). CIRCUMSTANCES OF THE DEATH | have set out below the following findings of fact that | made consistent with the evidence that | considered and in particular having regard to the live evidence from the driver of the Mercedes vehicle, providing expert evidence in the capacity as the designated Collision Investigator. Those findings of fact set out the circumstances of the death. e The collision involving Pat and a Mercedes motor vehicle occurred shortly before 2041 on the Friday 29 August 2014; Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 e The incident occurred in the westbound lane of the A303 at Stonehenge Down near Amesbury Wiltshire approximately 1.4 mile east of its junction with the A360 and at a point adjacent to Byway 11 positioned to the south of the carriageway; « The Mercedes was travelling westbound at a speed of between 40-50mph. e Pat was crossing the carriageway with one of his passengers intending to get back in his car which was parked at the entrance to Byway 11 having escorted one of his passengers to the north side of the carriageway in order to view Stonehenge when he was struck by the Mercedes; e The sun had set over half an hour previously and it was dark; e Pat was wearing dark clothing, his passenger wearing marginally more noticeable clothing; « The headlight glare from oncoming traffic would have made both Pat and his passenger not easily visible on the far side of the road verge when approaching from the east and they more likely than not were first visible when they were crossing the eastbound side of the highway and would have been silhouetted as moving objects by the oncoming vehicle headlights; e There was insufficient time for the driver of the Mercedes to take avoiding action once Pat had started to cross the carriageway and the driver had become aware of Pat on the carriageway; ¢ As a result of the collision Pat sustained an unsurvivable brain injury and having been taken to Southampton General hospital died at 2130 on 30 August 2014. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to a 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 those concerns to you. The MATTERS OF CONCERN are as follows. — (1) At the end of the Inquest | heard live evidence from [BEEBE who had prepared a helpful Traffic Management and Road Safety Assessment. | have enclosed a copy of that report with this letter as it includes helpful diagrams and maps to help explain the issue. He gave evidence having visited the scene that indications of activity on Byway 11 would appear to be limited to the area in the immediate vicinity of the A303 itself being used by the public as a car park or a stopping point so as to enable the occupants of vehicles, as indeed was the case with Pat and his passenger, to get a better view of the Stonehenge Monument lying to the north of the A303. Clearly the public are using this area in this manner and | am therefore concerned that there is a risk of future deaths occurring in similar circumstances if action is not taken. It was not (J opinion that the rest of Byway 11 was being actively and frequently used as a green lane. Byway 11’s current designation is as a BOAT (Byway Open to All Traffic). In Highway Law the right of the public to use such a right of way is pass and repass along it. The right does not extend in the absence of an emergency to parking. explained that discussions have taken place with the owner of the land, The National Trust and also with Wiltshire Council Rights of Way Department and their legal team with a view to possible closing of the terminal 600 metre section of Byway 11 Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 laying immediately south of the A303 and the Stonehenge Monument, downgrading Byway 11 down to a Bridleway and then diverting the bridleway along a current permissive path on National Trust Property so that the diverted Right of Way will then join Byway 12 approximately 400 metres south of the A303. The explanation and a plan are found on the final page of [Re port. | can entirely see the logic of this proposal and fully support the proposal as a means of addressing my concern relative to the area at the northernmost point of Byway 11. Such a modification would stop this area being used as a car park so as to facilitate free viewing access to the Stonehenge Monument. (2 ~~ Even if the above proposal is adopted in co-operation with the National Trust and Wiltshire Council | have however a further concern that in my view it is reasonably foreseeable that the problem currently associated with the area adjacent to the point at which Byway 11 joins the A303 will move approximately 390 metres west to the point at which Byway 12 connects to the A303. | know the area well and | can just see the problem shifting to this particular location and that concerns me from the point of view of the prevention of future deaths as if not addressed at this point could again lead to another fatality occurring in similar circumstances following the closure of Byway 11. | heard evidence from (J that Byway 12 is actively used as a green lane and | am fully aware that any modification to Byway 12 due to its use as a connecting green lane between the A303 and the A360 is likely to be highly controversial and political but that does not remove the concern that | have that there in my view is a reasonably foreseeable risk in the future if the terminal end of Byway 11 is closed. It is with this in mind and having considered the matter further after the inquest that | have included in the list of recipients of this Regulation 28 Report, The Department of Transport and English Heritage. The reason for this is of course last year the issue of the A303 generally in this area, following the closure of the A344, has prompted a review of the highway infrastructure in this area from the point of view of diverting the A303 or indeed as regards the funding of a tunnel through which the A303 would pass underground in the vicinity of the Stonehenge Monument and | would therefore like my concerns relative to the issues raised in this report relative Byway 11 and Byway 12 south of the A303 to be taken into consideration. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the recipients of this Regulation 28 Report have the power to take such action with the National Trust and Wiltshire Council addressing Item (1) and all four recipients addressing Item (2). YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 June 2015. |, the Coroner, may extend the period upon request. 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; c/o NE Watkins & Gunn Solicitors, Sussex House, 17 Gold Tops, Newport, NP20 4PH EE 0 ME B.C. Burton Copeland Solicitors, 51 Lincoln's Inn Fields, London WC2A 3LZ | have also sent it to Po of the Road Safety Unit, Wiltshire Police, who may find it useful or of interest. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 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 17 April 2015 Signature| Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
3 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.
ENGLISH HERITAGE From The Chief Executive Kate Mavor 11 JUN 231 Mr David W G Ridley == Senior Coroner for Wiltshire and Swindon nd Wiltshire & Swindon Coroner’s Office 26 Endless Street Salisbury Wiltshire SP! IDP 9 June 2015 Our Ref: CEO-EH-15-047 Dear Mr Ridley Thank you for sending through a copy of your Regulation 28 Report to Prevent Future Deaths pertaining to the death of Patrick Derek Sturtivant which was sent to [EEE in April 2015. As you may be aware, the Historic Buildings and Monuments Commission for England (Historic England) is the Government’s statutory adviser regarding the historic environment, and prior to | April also looked after the National Collection, which included Stonehenge. From | Apri stepped down as Chief Executive and the National Collection is now managed by the English Heritage Trust (known as English Heritage) and | am now responding as the new Chief Executive of the English Heritage Trust. | would like to begin by expressing our great sadness at the death of Mr Sturtivant on 30 August 2014. | have read your report and understand and share your concerns. ! would like to confirm that English Heritage is in full support of your views to downgrade Byway || to a Bridleway and close this to vehicular access. | also share your concern around the transferral of the current issue from Byway || to Byway 12 that this closure may cause, and the subsequent increase of risk that may ensue. No action has been taken recently by English Heritage to review the use of Byway || or Byway 12. We would be happy to work with Wiltshire Council and the police regarding the matter in order to prevent the risk of another tragedy around these junctions. AB “be, Ss \3 s fe o, Aa We have an access to information policy, so anything you send us may become public. 3 i if i i ality of o| ity as a service provider and an employer. 3 LS English Heritage is committed to achieving equality portunity ice provi , ployer Stonewall os AB The English Heritage Trust is a charity, no. 1140351, and a company, no. 07447221, registered in England DIVERSITY CuARITON ENGLISH HERITAGE In summary, | would like to stress once more that we are in full support of the downgrading of Byway I1 to a Bridleway and to close this to vehicular access and that we share your concerns about the impact that this will have on Byway 12. On behalf of English Heritage, | believe that vehicular access to Byway || and Byway 12 should be reviewed as a matter of urgency to improve safety. Yours sincerely pind Kate Mavor Chief Executive The English Heritage Trust is a charity registered in England, charity no. 1140351 and a company registered in England, Company no. 07447221
janet.tomlin@nationaltrust.org.uk Direct line: +44 (0) 1672 538013 29 May 2015 National RECEIVE Trust 3- JUN 2085 MrDavidWGRidley ee Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office 26 Endless Street Salisbury Wiltshire SP1 1DP Dear Mr Ridley Response to Regulation 28 Report — Fatal Accident on 29 August 2014 | am replying to your report dated 17 April 2015, concerning the death of Patrick Derek Sturtivant following a collision on the A303 on 29 August 2014. Please accept these comments as the response from me, as General Manager for the Wiltshire Landscape property portfolio, for and on behalf of the National Trust. | have not been able to find a record of any discussions between PC Appleton and the National Trust regarding the possible closing of the terminal section of Byway 11. My comments are therefore based entirely on the report, and the supporting traffic management and road safety assessment. We would be supportive of a proposal to close the terminal 600 metre section of Byway 11, downgrade this to a Bridleway, and divert the Right of Way along a permissive path to Byway 12 if this is a step that Wiltshire Council wish to take. With regard to the second recommendation, the National Trust is contributing to discussions with the Department for Transport about proposals for a tunnel for the A303 and we note that the Report has already been sent to the Secretary of State for Transport. Yours sincerely ZF Sromhin General Manager Wiltshire Landscape Property Portfolio National Trust President: HRH The Prince of Wales Avebury Estate Office Regional Chair: Clare Broom High Street Regional Director: Mark Harold Avebury Wiltshire SN8 1RF Registered office: Tel: +44 (0)1672 539250 Heelis, Kemble Drive, Swindon, Wiltshire SN2 2NA Fax: +44 (0)1672 538038 Registered charity number 205846 www.nationaltrust.org.uk To David W G Ridley From Janet Tomlin National Date 29 May 2015 Trust Subject Response to Regulation 28 Report to Prevent Future Deaths, 17 April 2015 Please find enclosed the response to the Regulation 28 letter dated 17 April 2015. As discussed with the Coroner's office on 28 May 2015, whilst both Tim Parker (as Chairman) and Janet Tomlin (as General Manager) were both originally contacted, there will not be two separate replies; this is the collective response from the National Trust. National Trust President: HRH The Prince of Wales Avebury Estate Office Regional Chair: Clare Broom High Street Regional Director: Mark Harold Avebury Wiltshire SN8 1RF Registered office: Tel: +44 (0)1672 539250 Heelis, Kemble Drive, Swindon, Wiltshire SN2 2NA Fax: +44 (0)1672 538038 Registered charity number 205846 www. nationaltrust.org.uk
Wiltshire Council ==. Where everybody matters 12™ June 2015 Highways and Transport Mr David Ridley County Hail Senior Coroner Bythesea Road Lloyds Bank Chambers Trowbridge 6 Castle Street Wiltshire Salisbury BA14 8JN SP1 1BB Your ref: Our ref : CB/PK/DT/MM 12.06 Dear Mr Ridley Re: Patrick Derek Sturtivant — Deceased A303 at Stonehenge | refer to your Regulation 28 Report dated 17 April 2015 provided to the Council. | can confirm that officers have now carefully considered the contents of your report and have now commenced the process of exploring a number of potential solutions. The Council has now undertaken an informal discussion with Highways England (formerly the Highways Agency) and contact has also been made with Historic England (formerly English Heritage). However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12. Whilst a solution is being explored by the various agencies the Police may be in a position to undertake appropriate enforcement action to prevent vehicles stopping along this section of the A303. As a multi-agency approach is required in order to determine an appropriate long term solution, the timescales for decision making and implementation are unfortunately difficult to determine at this early stage. However the Council would wish to make a formal request to extend the period for providing a formal response to the report and timetable for any proposed action to you under paragraph 28 (5) to twelve months. Yours sincerely Associate Director - Highways & Transport Wiltshire Council Tel: Email:
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