Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0286, written 20 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2015 |
|---|---|
| Reference | 2015-0286 |
| Deceased | Paul Coxon |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| 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.
Karen Dilks Senior Coroner for the City of Newcastle Upon Tyne co REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (QUE) irector Of Transport Strategy Gateshead Council Civic Centre Regent Street Gateshead NE8 1HH 4 CORONER | am Karen Dilks, Senior Coroner for the City of Newcastle Upon Tyne 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. tou /iwwnw legislation, gov.uk/ukoga/2009/25/schedule/S/oaraaraphi7 http://www. legislation.gov.uk/uksi/201 3/1629/part/7/made 3 INVESTIGATION and INQUEST On 17/12/2014 | commenced an investigation into the death of Paul Coxon, aged 40 years. The investigation concluded at the end of the Inquest on 15th July 2015. The conclusion of the Inquest was ACCIDENTAL DEATH. Mr Coxon having suffered injuries when struck by a motor vehicle on the A1 at 9 Redheugh Bridge south bound slip road Gateshead on the 13” December 2014. The cause of death was TRAUMATIC BRAIN INJURY. 4 CIRCUMSTANCES OF THE DEATH Paul Coxon was generally fit and well. On the evening of the 13"° December he consumed alcohol during a social evening. He walked onto the A189 Redheugh Bridge. Whilst on the south bound slip road off the A189 he crossed the carriageway directly into the path of an oncoming vehicle. The road layout is such the driver visibility of any potential hazard is limited. The speed limit is such that it is significantly impacts upon reaction time once a hazard becomes visible. A safe designated underpass crossing point is signposted but not illuminated. The incident on the 13" December occurred during the hours of darkness. At the time of the incident Mr Coxon was under the influence of alcohol. As a result of the incident he sustained a traumatic brain injury that caused his death. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Inadequate signage giving guidance to pedestrians of safe crossing points (2) Lack of illuminated signage to assist pedestrians in the hours of darkness (3) Appropriateness of 50 mile per hour speed limit on a complex slip road where driver visibility is limited and reaction time to any hazard significantly impaired as a result Lord Mayor’s Gallery, Civic Centre, Barras Bridge. Newcastle Upon Tyne, NE1 8QA Tel 0191 2777280 | Fax 0191 2612952 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe vou Director Of Transport Strategy have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" September 2015. |, 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 rt to the Chief Coroner and to the following Interested Persons (the deceased parents) | have also sent it to PC AE Brown, nvestgator Northumbria Police who may find it useful or of interest. | 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. Dated 20 July 2015 Signature Senior Coroner for the City of Newcastle Upon Tyne Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QA Tel 0191 2777280 | Fax 0191 2612952
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.
CUSTOMER
SERVICE
EXCELLENCE
{Gateshead
Council _—=
www. gateshead. gov.uk
Karen | Dilks LL.B My Ref.
H.M. Coroner Your Ref:
Coroner's Court
Civic Centre
Barras Bridge
i 03 AUG 2015
Newcastle upon Tyne
NE18PS
Date: 31 July 2015
Dear Ms Dilks
Senior Coroners Report into the Death of Paul Coxon
| acknowledge receipt of your Report which was sent to me with a covering letter dated 20
July 2015.
You advised therein that the evidence that you had considered revealed matters giving
rise to concern. You further advised that in your opinion there was a risk that future deaths
would occur unless action was taken. In the circumstances you stated that it was your
statutory duty to report to me that the matters of concern were as follows:
1. Inadequate signage giving guidance to pedestrians of safe crossing points.
2. Lack of illuminated signage to assist pedestrians in the hours of darkness.
3. Appropriateness of 50mph speed limit on a complex slip road where driver
visibility is limited and reaction time to any hazard significantly impaired as a
result
My observations, using the same numerical reference are set down below:
4. An additional sign will be erected at the top of the steps (adjacent to the south
east slip) which leads to the ‘underpass’. This will indicate the presence ofa
pedestrian route (via steps) and identify the pedestrian destination. Investigative
work will be undertaken to confirm that the pedestrian route is appropriately
signed on both sides of the bridgehead. This work will be completed within three
months from the date of this letter.
In respect of the ‘underpass’ itself the term is actually misleading. It is an open
span bridge with 5/6m lighting columns on the access road below to either side
providing adequate night time lighting levels.
Gateshead Council Civic Centre Regent Street Galeshead NE8 1HH a ‘NY
Tel 0191 433 3000 Vrs’
EY. Communities and Environment « Strategic Director Paul Dowling INVESTORIN PEOPLE
2. Requirements and guidance for illumination of road traffic signs is contained
within the Department for Transport’s ‘Traffic Signs, Regulations and General
Directions’ document. Pedestrian signage is not required to be illuminated and
the document does not contain discretionary advice suggesting it may be
appropriate to do so. Accordingly, whilst | note your concern, 1 do not intend to
take action in this regard.
3. Again, your concerns are noted, however it is my belief that a 50mph speed limit
is entirely appropriate for this section of road.
A member of my staff met with the Police investigating officer at the site shortly
after the accident. The investigating officer considered that forward visibility was
generally adequate put that the potential for a pedestrian to step out onto the
carriageway did give rise to concern.
Although it was not mentioned in your report, following the investigation into the
accident and the aforementioned meeting with the police | took immediate steps
to minimise the hazard relating to the presence of pedestrians on the
carriageway.
The guardrail currently in situ along the footway in question terminated at the
commencement of the bus stop layby at the time of the accident. The
associated bus stop had not been observed for a number of years and there
appeared to be no likelihood of it being brought back into use in the near future.
The, quite extensive, gap in the guardrail therefore served no current useful
purpose and | accepted that it could potentially encourage pedestrian activity on
the carriageway at an inappropriate location. | therefore commissioned the
introduction of infill panels. These were in place within three weeks of the
accident.
| believe that my actions significantly reduced the risk of future
accident of this nature.
occurrence of an
| am content for my response to be distributed as considered appropriate by the Chief
Coroner.
If you have any queries or remaining concerns about the content of this letter | would be
happy to discuss further
Yours sincerely
Service Director, Transport Strategy
Communities and Environment
QiTsi
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