Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0506, written 22 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 | 22 Jul 2015 |
|---|---|
| Reference | 2015-0506 |
| Deceased | James McGeown |
| Coroner | Andrew Cox |
| Coroner area | Worcestershire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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. HE ransportation Commissioning & Logistics Manager, Worcestershire County Council, County Hall, Spetchley Road, Worcester 2. 3. 1 | CORONER | am Andrew James Cox, Assistant Coroner, for the coroner area of Worcestershire 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. 3 | INVESTIGATION and INQUEST On 20 March 2015 | commenced an investigation into the death of James Gerard MCGEOWN then aged 46. The investigation concluded at the end of the inquest on 22 July 2015. The conclusion of the inquest was road traffic collision the medical cause of death being 1a) multiple injuries . 4 | CIRCUMSTANCES OF THE DEATH | Mr McGeown was seen to overtake another vehicle. He was described at travelling well in excess of the speed limit of 7Omph. Toxicology evidence revealed that he was also driving under the influence of alcohol. The Collision Investigator found that Mr McGeown was not wearing a seat belt. At the time Mr McGeown overtook the other car, his vehicle was seen to "wobble" this caused the vehicle to step towards the nearside. In attempting to recover the situation Mr McGeown oversteered and collided with the central reservation, crossing over it and in to the opposing carriageway. 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) | enclose a copy of the Collision Invesstigator's Report, prepared » | draw your attention to paragraphs 6.13 and 8.6. has identified an "undulation" in the road surface. It is likely that this caused the "wobble" seen by the witness immediately prior to Mr McGeown losing control of his vehicle. In his evidence to the Court, EE said that he had driven this stretch of road on several occassions as a consequence of this incident. While travelling within the speed limit the undulation causes drivers no concern. At higher speeds (om) a | limit the undulation causes drivers no concern. At higher speeds (95mph) = described the undulation as causing a loss of control that may have caused an unsuspecting driver to have a collision. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 16 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 sent a copy of my report to the Chief Coroner and to the following Interested | 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. Signed AJ Cox H M Assistant Coroner 22nd day of July 2015
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