Prevention of Future Deaths reports · 2015

Julios Catachanas

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 report1 May 2015
Reference2015-0174
DeceasedJulios Catachanas
CoronerSean McGovern
Coroner areaWarwickshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Warwickshire County Council (PDF)
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.

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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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