Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0103, written 10 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Mar 2016 |
|---|---|
| Reference | 2016-0103 |
| Deceased | Derek Nixon |
| Coroner | Ian Smith |
| Coroner area | Stoke on Trent and North Staffordshire |
| 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1}
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Project Engineer ~ Casualty Investigation
Accident Investigation Unit
Staffordshire County Council
1 Staffordshire Place
STAFFORD
ST16 2LP
4 | CORONER
| am lan Stewart Smith,senior coroner, for the coroner area of Stoke-on-Trent & North
Staffordshire.
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 9" April 2015, | commenced an investigation into the death of Derek Nixon aged 80
years. The investigation concluded at the end of the inquest on18th February 2016. The
conclusion of the inquest was that Mr Nixon died as a result of multiple injuries due to a
toad traffic collision.
4 | CIRCUMSTANCES OF THE DEATH
On the morning of 2nd April 2015 the deceased walked into Leek town and attended a
routine appointment with his doctor on Fountain Street, Leek, leaving the surgery at
approximately 9.45am. He proceeded down Fountain Street towards Ball Haye Street
and Derby Street. At 9.58am he walked across the front of a rigid goods lorry which had
stopped in Ball Haye Street for traffic lights. The driver of the lorry did not see the
deceased due to his elevated position in the lorry cab. The lorry moved forwards as the
lights changed just as the deceased was immediately in front of the lorry and he was
knocked to the ground, passing under both front offside wheels and sustaining fatal
injuries. Police and paramedics attended and he was pronounced dead at 10.16am.
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-
| heard evidence at the inquest on 18" February 2016 of the various changes which had
been made to the road and pavement infrastructure at Ball Haye Street, Fountain Street
and Derby Street, Leek. | noted that certain iron railings at the end of Fountain Street
had been removed. | heard police evidence that many pedestrians, by far the majority,
when walking down Fountain Street then walked across Ball Haye Street at the ‘Keep
Clear’ point because there was nothing to prevent them. The pedestrian crossing is a
few yards down the road but human beings will take short cuts when on foot, even if this
puts them in danger. | would ask that the council looks afresh at this area and consider
what modifications might be made. Railings might be appropriate.
| make no comments on the remainder of the town centre road alterations, these did not
feature in the inquest and are therefore outside my remit.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and/or
your organisation 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 Friday 6” May 2016. |, the senior 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
Persons:
1. a :: of the deceased)
2. Collision Investigation Unit, Staffordshire Police
{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.
40" March 2016
Signed by Anthony F Curzon Assistant Coroner on behalf of lan S Smith, Senior
Coroner
fog
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.
Staffordshire County Council Mri S Smith HM Senior Coroner Stoke-on-Trent and North Staffordshire Coroner's Area Accident Investigation Unit Staffordshire County Council 2 Staffordshire Place Tipping Street Stafford Coroner's Chambers STi6 20H 547 Hartshill Road Stoke-on-Trent Telephone 01785 278160 ST4 6HF ena: Dear Mr Smith, 19" July 2016 Re: Derek Nixon (Deceased) | refer to your Regulation 28 Report regarding the inquest into the death of Derek Nixon and your comments concerning the changes made to the road and pavement infrastructure, specifically at the junction of Ball Haye Street and Fountain Street Leek. This letter is in response to your matters of concern recorded in section 5 and the actions you believe should be implemented in section 6 of your report. An investigation has taken place which assessed the current road layout and the existing pedestrian facilities at this location. As part of the investigation, pedestrian surveys were undertaken and these indicated that pedestrians are extensively utilising the Zebra crossing facility near to Queen Street and the crossing facility at the War Memorial. A significantly lower number of pedestrians are choosing to cross at the northem radius of the junction when travelling westbound from Fountain Street. As part of this investigation, two measures have been recommended. Firstly it is proposed to not to reinstate the ‘Keep Clear’ marking on Bali Haye Street at the junction of Fountain Street which was recently removed as part of planned highway maintenance works. Secondly it is proposed to install a short section of guardrail around the northern radius of the Fountain Street junction. It is proposed that these measures are funded from the 2016/17 financial year Capital Programme and be carried out alongside planned highway maintenance works in the Leek area. vat ; ee ; Staffordshire < County Council | hope the information provided within this letter is useful. Please let me know if you require anything further. Yours sincerely, Principal Transport Planner (Interim Accident Investigation Unit Manager) con the knot unites ge es a : a ==
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