Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0174, written 1 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2015 |
|---|---|
| Reference | 2015-0174 |
| Deceased | Julios Catachanas |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 1S BEING SENT TO: 1. Chief Executive — Warwickshire County Council 1 | CORONER lam S McGovern, senior coroner, for the coroner area of Warwickshire 2 | CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and reguiations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 7 January 2015 | commenced an investigation into the death of Julios CATACHANAS 25 years old. The investigation concluded at the end of the inquest on 4 May 2015. The conclusion of the inquest was that Mr Catachanas died from a road traffic coilision.. 4 | CIRCUMSTANCES OF THE DEATH On 23 December 2014 Mr Catachanas was driving his car along Campden Road to the junction with the Fosseway during the hours of darkness. There were appropriate Give Way signs and a Checkerboard at the junction however Mr Catachanas collided with a lorry travelling along Fosseway, 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) | was concerned that street lighting was not present at this junction (2) That consideration be given to staggering the junction to prevent vehicles travelling aiong Campden Road from driving ‘straight through’ across Fosseway. § | ACTION SHOULD BE TAKEN in my opinion action should be taken fo prevent future deaths and | believe you as Chief Executive of Warwickshire County Council 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 25 June 2015. 1, 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 musi 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 - the family of Mr Catachanas iam 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 fo 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. +" May 2015 Senior Coroner S McGovern
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.
Warwickshire County Council Resources Group Legal Services Shire Hall, Warwick, CV34 4RL DX 723362 Warwick 5 Sarah Duxbury LLB Hon DipLG Head of Law & Governance Mr S McGovern Senior Coroner Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL 25th June 2015 Dear Mr McGovern REPORT TO PREVENT FUTURE DEATHS UNDER REGULATION 28 CORONERS AND INTO THE DEATH OF JULIOS JUSTICE ACT 2009 FOLLOWING CATACHANAS INQUEST I am writing in response to the concerns raised by your investigation and report of 1st May 2015 into the death of Mr Julios Calachanas. Mr Catachanas died as a result of a road traffic collision which occurred on 23rd December 2014 during the hours of darkness at the junction of the B4035 Campden Road with the A429 Fosseway, known locally as Portobello Crossroads. Warwickshire County Council has carefully considered your report and the matters of concern raised in it, namely: 1. That street lighting was not present at this junction. 2. That consideration should be given to staggering the junction to prevent vehicles travelling along Campden Road from driving straight through Fosseway. Notification of the collision was received by the County Council on 29 December 2014. Following this notification Carolyn Burrows, Team Leader and Lee Williams a Road Safety Engineer, from the Traffic and Road Safety Group attended the site with Ian Connolly, the traffic Management Assistant from Warwickshire and West Mercia Police's Road Safety Team. This site visit is a normal procedure following any fatal road accident. The purpose of the site visit is to ascertain whether for safety reasons there are any immediate actions that need to be taken in respect to the highway and any possible defects and/or improvements that should be carried out without delay. At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken. The County Council undertakes an annual review of all collision cluster sites across the County. A cluster site is defined as a location that has had 6 or more personal injury collisions in the last 3 years. However not all sites are treatable as there are many occasions where there are no patterns to the collisions. Funding of £350,000 has been allocated to casualty reduction schemes across the county for 2015/2016. Lextel Practice Management Standard l-a w Society Accredited ' “ W ' H Au 1 INVKSTOX TN PEOPLE Printed on 100'% recycled paper As part of the annual cluster site assessment the review of Portobello Crossroads revealed that there had been 11 personal injury collisions in the last 3 years, of which 4 had occurred during the hours of darkness. The assessment identified that there has been a significant increase in the number and severity of collisions occurring at this junction over the last two years. The junction was therefore identified as a cluster site location for the implementation of remedial measures this financial year. Officers have carried out further detailed investigations at the junction and have assessed the potential impact of introducing various remedial measures. Given this investigation, the following actions have been proposed. (cid:127) On-line geometric improvements to reduce 'see through’ effect of the side roads (cid:127) New signing to highlight the presence of the junction to drivers travelling on both the major and minor arms; (cid:127) Road marking improvements to make the junction more conspicuous to drivers (cid:127) travelling on all approaches; In view of the number of injury collisions that occurred in the hours of darkness, a street lighting scheme will be implemented to make the junction more visible at night; (cid:127) The road studs will also be upgraded to make the layout of the junction more visible at night; (cid:127) Provision of central islands to help align vehicles, thus increasing visibility. Islands will also highlight the presence of the junction to drivers. (cid:127) Removal of vegetation will be undertaken to improve stopping sight distances; (cid:127) The carriageway will be resurfaced to increase skid resistance on approach and through the junction. In our view introducing these measures will significantly reduce the occurrence of personal injury collisions at this junction. It is proposed that the above measures, which are subject to detailed design and consultation, will be implemented this financial year. The County Council has taken very seriously your report and the concerns raised in it. I do hope that through the measures the Council is proposing to implement you, and the family of Mr Catachanas, can be assured of the County Council’s commitment to reducing the number of such tragedies in the future. Yours sincerely
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