Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0127, written 31 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 | 31 Mar 2016 |
|---|---|
| Reference | 2016-0127 |
| Deceased | Sheila Slater |
| Coroner | ARW Forrest |
| Coroner area | South Lincolnshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
AR W Forrest itm, ercp, FRcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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: The Rt Hon Patrick McLoughlin MP Secretary of State for Transport 13 1 | CORONER !am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire. 2 | CORONER’S LEGAL POWERS and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 3 | INVESTIGATION and INQUEST The investigation concluded at the end of the inquest on 30" March 2016. The conclusion of the inquest was Road Traffic Collision 4 | CIRCUMSTANCES OF THE DEATH Sheila Slater was the front seat passenger in a car driven by her husband. They were driving north along the A16 near Crowland. On reaching the staggered junction with the B1166, he manoeuvred into the Central reservation with the intention of turning right into the A16. Mrs Slater died at the scene of the subsequent collision. 5 | CORONER’S CONCERNS Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk On 28"" May 2015 | commenced an investigation into the death of Sheila Slater, Age 81. The B1166 and continued into the path of an oncoming South bound vehicle travelling on AR W Forrest ium, Frep, FRcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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 staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was opened in 2010. As with all of the other staggered junctions in Lincolnshire it was built to DFT specifications. Since it was opened there have been 3 fatalities associated with this junction (2 at the junction and one on the approach to the south bound island) and 10 injury producing collisions. There have been fatalities at the other staggered junctions in Lincolnshire. DFT and Highways England have been made aware of the problems associated with these junctions both by S.28 reports and correspondence from officers of Lincolnshire County Council. At the inquest, into Mrs Slater's death evidence was given to the effect that this particular junction could be made safer if it were to be replaced by a roundabout but that local funding was not available for this purpose. Witnesses also were concerned about the safety record of other staggered junctions in Lincolnshire. 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, particularly given that these junctions have been built to DFT specifications. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 May 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest tum, rep, FrcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire Persons: ( 2. FY Road Safety (Accident Investigation) Manager, Lincolnshire Road Safety Partnership. 3. Paul Cooper (Acting Senior Coroner, South Lincolnshire, wef 1 April 2016) 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. 31° March 2016 ARW Forrest ) n. H M Senior Coroner for South Lincolnshire Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk
2 responses 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.
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P4DR Department for Transport Paul S Cooper HM Acting Senior Coroner for South Lincolnshire Unit 1, Gilbert Drive Endeavour Park Boston PE21 7TQ Thank you for your letter of 4 April enclosing Professor Forrest’s Regulation 28 Prevention Report in respect of the death of Mrs Sheila Slater. Naturally I am sorry to hear of the circumstances of Mrs Slater’s death. I note the professor’s view that the design of the junction may have contributed to the accident and that there may be similar problems at other staggered junctions in Lincolnshire. The Design Manual for Roads and Bridges, a publication sponsored by my department sets out the national standards for such junctions, however local authorities are responsible for road safety on the local road network, in this case Lincolnshire County Council. Section 39 of The Road Traffic Act 1988 puts a 'statutory duty' on local authorities to deliver an appropriate road safety education service and for the provision of a safe local road network. This includes road construction, accident investigation and analysis, traffic calming, setting speed limits and facilities for pedestrians and cyclists. It is up to individual authorities to determine how they meet their ‘statutory duty’ and any decision about installing a roundabout on a local road is entirely a matter for Lincolnshire County Council. Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns. I expect that Mr Alan Ball, the Road Safety (Accident Investigation) Manager who has also been copied in to the Regulation 28 Prevention Report, will be able to advise you and Lincolnshire County Council further in this matter.
The Great Western Hospital Marlborough Road Swindon SN3 6BB 30th December 2025 Private and Confidential Grant Davies Area Coroner for Wiltshire and Swindon Dear Mr Davies Re: Coroner’s Regulation 28 Report – Anna Marie Burns, We write in response to the Regulation 28 Prevention of Future Deaths Report received by the Trust on the 19th November 2025. The report raised concerns about the circumstances which led to the tragic death of Anna Marie Burns. I would like to express my deepest condolences to Anna’s family and acknowledge the distress caused. Thank you for the clarity and detail of your report. We recognise the seriousness of the concerns you have raised and are committed to addressing them with care and careful consideration. The report asked the Trust to respond to the consideration that notification to relevant parties other than the GP be undertaken in cases where an admission due to an overdose had occurred. The report noted that the Trust had no duty of care to provide a copy of the discharge summary to the community prescriber (CGL – Swindon) and that this omission was neither causative nor contributory to the death of the patient. Nevertheless, the report asked that the Trust ‘consider that notification to relevant parties (especially methadone prescribing authorities) regarding hospital admissions for drug overdoses takes place in the same manner as GPs highlighting the nature of the admission (i.e. overdose).’ Actions taken An assessment of all options available to the Trust to improve communication with community prescribing agencies by the Deputy Chief Medical Officer. Considerations included sharing of confidential patient information in a secure manner. The Trust wide guideline on ‘Opioid Substitution Therapy’ was ratified on the 4th September 2025. This guidance governs practice around in-patients admitted on or commenced on Opioid Substitution Therapy. Key points are: 1. Mandating referral to CGL (if in area) or relevant out of area provider and community pharmacy on commencing OST as an in-patient. 2. Mandating contact with CGL or appropriate provider on prescription of OST for patients admitted who are on an existing program. An automated pop-up message directing prescribers of OST/antidotes (e.g. naloxone, flumazenil) has been generated on EPMA (electronic prescribing platform). This will prompt the prescriber to be aware of the Opioid Substitution Therapy policy and allow referral/information sharing with community prescribers and community pharmacy. The learning has been shared anonymously across the Trust in governance and professional forums. The Trust is committed to ensuring that the lessons from this case contribute to meaningful and lasting improvements in our services. Once again, I wish to extend my sincerest condolences to Anna’s family and provide some assurance that we are committed to learning from this sad experience. Yours sincerely, Managing Director Copy to: Chief Coroner, Care Quality Commission
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