Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0200, written 27 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 | 27 May 2015 |
|---|---|
| Reference | 2015-0200 |
| Deceased | Nicholas Stocks |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire (West) |
| 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.
ANNEX A 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. The Chief Constable West Yorkshire Police 2. Chief Executive Kirklees Council 1 CORONER I am Mary Burke, assistant coroner, for the coroner area of West Yorkshire Western Area 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 28th September 2012, an investigation was commenced into the death of Nicholas Gary Stocks aged 55 years. The investigation concluded at the end of the inquest on 17th March 2015. The conclusion of the inquest was that Mr Stocks died from multiple traumatic injuries and I recorded a conclusion that Nicholas Gary Stocks had died as a result of a Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH On Thursday 27th September 2012, Mr Stocks and his partner walked along Lower Denby Lane, Huddersfield and were waiting to cross the A635 Barnsley Road. At that point in time a road traffic collision occurred between two vehicles. A BMW which was travelling along the A635 Barnsley Road in the direction of Holmfirth. This vehicle was struck by a Vauxhall Astra which emerged from Dry Hill Lane without stopping. As a result of the collision, the BMW vehicle struck Nicholas Gary Stocks and his partner. Tragically, Mr Stocks suffered fatal injuries and his death was confirmed at the scene. Evidence was presented at the inquest which confirmed that another road traffic collision had occurred at the junction of Dry Hill Lane and the A635 Barnsley Road earlier the same day at approximately 3.00 pm, and as a result the Give Way sign on Dry Hill Lane had been demolished. The Police Officer in attendance had reported this damage via radio to the control room unit at West Yorkshire Police and requested that Kirklees Council be contacted and the damage reported. Several attempts were made to contact Kirklees council by telephone, but no response was received and therefore an email was sent and an automated acknowledgement was received the same day. The Give Way sign remained damaged at the time of this fatal road traffic collision. Evidence at this inquest also revealed that on Dry Hill Lane, the white line Give Way markings and the white painted triangle giving notice of a Give Way junction, had worn to such an extent, that they were no longer clearly visible. Both the A635 Barnsley Road and Dry Hill Lane had been inspected by Kirklees Councils Safety Inspectors periodically and each road had been inspected in recent months. Notwithstanding this, the deterioration in the road markings had not been identified, as presenting a safety risk and no repairs undertaken. In addition an almost identical road traffic collision had occurred at the scene on 5th November 2011 and West Yorkshire Police duly attended and identified that the approach and junction with Dry Hill Lane and Barnsley Road were poorly marked and poorly lit, and were factors with regard to the incident. It appeared from the evidence presented at the inquest, that these details were not reported by West Yorkshire Police to Kirklees Council. 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. – West Yorkshire Police (1) I am concerned that the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council. I would ask you to review the system presently in place to ensure that all future reports are made and fully reported (2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken. I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out. (3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon of 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified. Kirklees Council (1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat. (2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads. (3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council. (4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained. I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future. (5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times (6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police are in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public. (7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed. (8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area. 9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane. I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 23rd July 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: Messrs. Kennedys, Solicitors who may find it useful or of interest. 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 M. T. Burke 27th May 2015 Assistant Coroner
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.
CONFIDENTIAL WEST YORKSHIRE Force Headquarters: ‘ Labumum Road Wakefield WFi 3QP Tel: Chiet Oncor Teom — Es Date: 7 July 2015 a T 9, Assistant Coroner Burke Her Majesty’s Coroner “s City Courts “ The Tyris Bradford. BD11LA Dear Assistant Coroner Burke Re: Nicholas Gary Stocks, deceased Report to Prevent Further Deaths Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013 You wrote to the Chief Constable, in May 2015, following your inquest into the death of Nicholas Gary Stocks that occurred on 28" September 2012. | am writing on behalf of Temporary Chief Constable Collins to address your Regulation 28 notice. | note there are three matters of concern raised in relation to West Yorkshire Police. | have replicated these below with my response detailed below each item. (1) 1 am concerned that the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council. | would ask you to review the system presently in place to ensure that all future-reports are made and fully reported. For many years there has been a procedure in place between WYP and the Local Authorities for reporting damage caused to street furniture and defects in the public highway. There are specific forms (known locally as B2D and PO15) for this purpose that all staff within the organisation have access to. These are currently sent either via post or direct to the relevant department via email. | have taken this opportunity to review our reporting processes in regard to reports made to alll five local authorities within our area. This review will involve ensuring that the postal/email addresses automated by our current systems are up to date and that there is the facility to send reports to a generic mailbox which is monitored by several people rather than an individual thereby ensuring the reports are received and dealt with in a timely manner. ! am currently in liaison with the five local authorities to ensure that the contact details we hold, both email and telephone, will direct the information/report to the correct department to enable an appropriate response. Furthermore, | will ensure that contact telephone numbers for the CONFIDENTIAL 1) 3) 4) CONFIDENTIAL local authorities are preloaded onto our Force Communications system, thereby ensuring’the correct numbers are easily accessible to the communications staff. These contact numbers should cover “24/7” and allow the operator to speak to a representative. It is understood that it is not appropriate to leave a message on an answerphone or send an email in urgent cases. | will ensure that a Force wide communication is circulated to ensure that staff are reminded of the importance of submitting this information in a timely manner and that it is mandatory after the attendance at a road traffic collision where defects are identified. This will also be entered into Force Policy on dealing with collisions. In addition, where there is an obvious safety risk and the repairs/remedial action is required urgently contact will be made by communications staff via telephone to the local authority for the area. The operator will endorse on the police log the name of the person they spoke to, the details supplied and the estimated time of arrival indicated by the authority. All officers will be reminded of the need to conduct a thorough risk assessment of the location prior to leaving the scene and will not resume ‘until either, i) it is deemed safe to do so, or, ii) the local authority has attended, or, iii) the local authority have assesses the risk against their protocols or, iv) remedial works have been implemented to remove any risk to the safety of other road users. This will be endorsed on the log by the communications staff. The log will not be closed uniess the following questions are answered Have you undertaken a risk assessment of the scene? If so is it safe to leave? Has damage been caused to the road or street furniture or are there any other defects that have contributed to the collision? If so, has a form B2D or PO15 been submitted? My representative has met with Kirklees Council and can confirm that | now have up to date contact telephone numbers enabling my communications staff to speak to someone directly “24I7°. This has been updated on our Force Communications systems. It has been agreed that if the matter is urgent the authority will attend the scene within an hour. For none urgent cases the matter will be reported via the email system as detailed above. | propose that the above actions will be completed by the end of August 2015. (2) On the afternoon of the 27 September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hil! Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken. 1 would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out. | have liaised with Kirklees Council and have agreed that responsibility for this risk assessment is shared as follows: For incidents that the Police attend it will be for the attending officer to carry out the risk assessment and decide the urgency of any remedial action required. If the officer decides that the defect is so dangerous as to require immediate action then they should communicate this to the council via their control room and remain with the defect until the council attend. Once the council staff do attend the officer should explain their concerns. It will CONFIDENTIAL 1) 3) 4) CONFIDENTIAL ~“then be for the council staff member to carry out their own risk assessment as to the action they should take. At this point that the council would assume responsibility for the defect. As detailed at point 1) all officers will be reminded of the need to conduct a thorough risk assessment of the location prior to leaving the scene and will not leave the scene until either its deemed safe to do so, or the local authority has attended, or the local authority have assesses the risk against their protocols or remedial works have been implemented to remove any risk to the safety of other road users. This will be endorsed on the log by the communications staff. The log will not be closed unless the following questions are answered Have you undertaken a risk assessment of the scene? If so is it safe to leave? Has damage been caused to the road or street furniture or are there any other defects that have contributed to the collision? If so, has a form B2D or PO15 been submitted? As detailed at point 1) an up to date contact number from Kirklees Council has been obtained enabling communications staff to speak to someone directly “24/7’. This has been updated on our Force Communications system. It has been agreed that the authority will assess the risk based on their own internal processes and determine from the information given what level of response is required. If the matter is deemed urgent they will attend the scene within an hour. (3) 1 would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon of 27" September 2012 to report the damage to the give way sign. | heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. 1 wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, | wish to ensure this is rectified. On the afternoon of 27" Sept 2012 the West Yorkshire Communications operator rang the Highways Customer Service number. From call logs it has been established that the operator was on hold for 3 minutes 51 seconds prior to sending an email. | can confirm that we now have up to date contact numbers for Kirklees Council enabling staff to speak to someone directly “24/7". Our Force Communications system has been duly updated. | am assured by Kirklees Council that this phone will always have an operator. | sincerely hope that you will be satisfied and reassured by my response to the points you raised. Yours sincerely MA Mak Assistant Chief Constable Protective Services Ops CONFIDENTIAL
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