Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0389, written 28 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Sep 2015 |
|---|---|
| Reference | 2015-0389 |
| Deceased | John Roberts |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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: Highways Agency, E2 County Hall, Market Road, Chelmsford, Essex. CM1 1QH. 1 CORONER I am Caroline Beasley-Murray, HM SENIOR Coroner, for the coroner area of Essex 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. 3 INVESTIGATION and INQUEST On 10th March 2015 I commenced an investigation into the death of John Frederick Roberts who was 56 years of age. The investigation concluded at the end of the inquest on 23rd September 2015. The conclusion of the inquest was an Accident. 4 CIRCUMSTANCES OF THE DEATH On the 5th March 2015 at around 8:05am. Mr Roberts, a pedestrian, stepped out into Springfield Road, Chelmsford, Essex and was struck by a vehicle. He was transferred to The Royal London Hospital, Whitechapel and he died there at 2:09am on the 6th March 2015. The location of the accident is a complex intersection which includes a roundabout, and several joining roads and a traffic island. 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. – A well worn path across the central reservation indicates that pedestrians regularly cross the traffic island and the central reservation, putting themselves at serious risk. Sixty metres away is the nearest crossing which is not very evident. Consideration needs to be given to the designing of a safer junction. 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. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 22nd November 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 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 28th September 2015 Caroline Beasley-Murray 2
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: Essex Highways Agency. FCIU 1 CORONER I am Mrs Caroline Beasley-Murray, HM SENIOR Coroner, for the area of Essex 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. 3 INVESTIGATION and INQUEST On 29th January 2015 I commenced an investigation into the death of Erich Roland Speilmann who was 92 years of age. The investigation concluded at the end of the inquest on 23rd September 2015. The conclusion of the inquest was Accidental Death. The cause of death was 1a) Multiple Injuries 1b) Road Traffic Collision 11) congestive failure, bladder cancer. 4 CIRCUMSTANCES OF THE DEATH On the 28th January 2015, Mr Speilmann was crossing Alderton Hill, Loughton into the path of a vehicle that had slowed sufficiently to allow him to reach the middle of the road. A vehicle travelling in the opposite direction collided with him as he was attempting to reach the other side. He was conveyed to hospital and died later that day. 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. – The quality of the street lighting at the location may have contributed to the incident. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th January 2016. 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. FCIU 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 20th October 2015 Mrs Caroline Beasley-Murray 2
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