Prevention of Future Deaths reports · 2016

Kevin Ritson

Regulation 28 report to prevent future deaths, reference 2016 – 0284, written 10 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Aug 2016
Reference2016 – 0284
DeceasedKevin Ritson
CoronerDavid Roberts
Coroner areaCumbria
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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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

RE: Kevin David Ritson

THIS REPORT IS BEING SENT 70: 1. in - Corporate Director, Highways Department,
Cumbria County Council, The Courts, Carlisle, Cumbria CA3 8NA

CORONER

lam Mr David Llewelyn Roberts Senior Coroner for County of Cumbria
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.

http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www legislation. gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 10" August 2015 | commenced | commenced an investigation into the death of Kevin David RITSON,
aged 35 years. The investigation concluded at the end of the inquest 27th June 2016. The conclusion of
the inquest was:

1a) Multiple injuries

Conclusion: Accident

CIRCUMSTANCES OF THE DEATH

On the 4" August 2015 the deceased and a companion went for a motorcycle ride around Cumbria via
Penrith and Barrow. Whilst heading homewards north on the A595, on a left hand bend at Stangrah
Farm, the deceased lost control of his machine, crossing the central white line and came off and
entered the verge on the offside of the road. He was airlifted to Preston Hospital where he died of
unsurvivable injuries.

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 deceased was riding his motor bike through Stangrah Farm near Whitbeck. This had been the
scene of an earlier accident damage from which had removed a chevron warning sign. It was clear from
photographs that the road surface was not in good condition and holes had been patched. Evidence also
showed the road surface adhesion to be below standard.

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.

Whilst it is appreciated that many roads in the county require treatment the A595 is the main road to
Barrow and the south, the Coroner requests you consider taking action at this particular location to
upgrade the road surface and warning signs.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report. |, 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

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons,
| and her Solicitors Messrs. Hutcheon Law. | have also sent it to Chief Coroner who may find it
useful or of interest.

lam 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.

10.08.2016

Mr David Llewelyn Roberts Senior Coroner for County of Cumbria

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