Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0452, written 27 Oct 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 Oct 2015 |
|---|---|
| Reference | 2015-0452 |
| Deceased | Bartosz Bortniczak |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
Nicola Jane Mundy Senior Coroner for South Yorkshire (East District) ise REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: [a Head Of Service Highways Doncaster MBC Regeneration & Environment Civic L Building, 4th Floor DN1 3 1 CORONER : 1am Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District) ft 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 hito:/Avww legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On 17/11/2014 | commenced an investigations into the deaths of Bartosz Kacper Bortniczak who died from multiple injuries including haemothorax and dislocated cervical spine, Blake Reece Cairns who died from multiple injuries including transacted thoracic aorta and by ventricular lacerations, Jordanna April Louise Goodwin who died from a fractured skull, Arpad Kore who died from a transacted thoracic aorta and Megan Lea Storey who died from intra pleural and intra-cerebral haemorrhage due to blunt trauma to the chest and head. The conclusion for each of the inquests was Accidental death. 4 | CIRCUMSTANCES OF THE DEATH On the 15" November 2014 Bartosz Bortniczak was driving his motor vehicle along the A630 in Conisbrough. Blake Cairns, Jordanna Goodwin, Arpad Kore and Megan Storey were passengers in the vehicle. Mr Bortniczak entered a right hand bend on this stretch of road at a speed in the region of 73mph. As he steered through the bend he lifted his foot of the accelerator and/or braked causing the vehicle to spin, skid and cross to the opposing carriageway where it was in a collision with a vehicle travelling in the opposite direction. The five occupants of the vehicle being driven by Mr Bortniczak all suffered extensive injuries which rapidly proved to be fatal. Police Officers from the Traffic Division of South Yorkshire Police provided evidence that over the last 10 years there have been 18 incidents on this stretch of road, which included 10 fatalities and 2 serious injuries. The speed restriction is the National speed limit namely 6Omph. | 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) The speed restriction up to and through the bend is 60mph but drops to 40mph after the bend. Given the number of incidents on this stretch of road it would appear more appropriate for the reduced speed restriction to apply prior to the bend which was the subject of these inquests. Given the number of incidents in this area, | am concern that to leave the speed restriction at sixty miles per hour leads to circumstances continuing to create a risk of other deaths occurring. In the circumstances, it is my view that the speed restriction of 40mph should be moved so that it |__| is prior to the bend on this stretch of road. ee Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you PY 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 21 December 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons | R James HutcheonSolicitors, and to the LOCAL SAFEGUARDING BOARD. | 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 Senior Corone puth Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833
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.
Pm — —_ Contact: Fe Tel: (01302) 734499 Fax: Ms N Mundy Vai HM Coroner Minicom: South Yorkshire (East District) Website: www.doncaster.gov.uk Coroner's Court and Office Our Ref: 0116conisbroughA630/LG/SB Crown Court Your Ref College Road our rer DONCASTER Date: 14 January 2016 DN1 3HS Dear Ms Mundy Bartosz BORTNICZAK, Blake CAIRNS, Arpad KORE, Jordanna GOODWIN, Megan STOREY (deceased) DoD 15/16 November 2014; RTC Sheffield Road, Conisbrough | refer to your Regulation 28 report dated 27 October 2015 and sent to Doncaster MBC further to the conclusion of your inquest. lam P| Head of Service, with responsibilities for Waste and Highway Infrastructure. As you are aware, the Council was not involved in the inquest. Accordingly, on behalf of the Council, | would like to firstly express condolences to the families for their loss as a result of this tragic incident. Secondly, | thank you for providing the Council with copies of the relevant inquest documents and also for extending the time for the response to your report. The Council has noted your concern about the speed restriction on the relevant stretch of the A630. The Council is not aware of any previous concerns about the speed limit being raised by South Yorkshire Police. All relevant terminal speed limit signing is in place and is correct on all approaches. Similarly, all signing/lining on the carriageway was in place in accordance with the Traffic Signs Regulations and General Directions 2002. The road is also lit with overhead street lighting aiong its length. a roe Doncaster Council a ivi rdale, D DN1 3BU Civic Office, Waterdale, Doncaster Tlequatity mark w w © x= é = a > i However, the Council will always consider relevant issues relating to road safety as far as it can and the concerns you have identified are in the process of being considered. In short, | can confirm that, subject to the necessary due process for such a matter, the Council intends to take steps to reduce the speed limit on the relevant stretch of road to 40mph. Any changes to the speed limit would also be complimented with additional signing and road markings as appropriate. It is important to note however that changes to speed limits are governed by statutory processes requiring the drafting and publicising of Traffic Regulation Orders, formal consultations and relevant periods for comment or objection. It is therefore not possible to pre-empt the outcome of this necessary due process or indeed to provide a definitive timetable for action. However, in the event that the proposed alteration to the speed limit is approved following the relevant due process, it is anticipated that the Council would be ina position to implement the change by early summer 2016 at the latest. Yours sincerely LG Head of Service Waste and Highways Infrastructure rm uw fe r - = i > if 4 D CD equality mark Doncaster Council Civic Office, Waterdale, Doncaster DN1 3BU
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