Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0135, written 30 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 | 30 Mar 2016 |
|---|---|
| Reference | 2016-0135 |
| Deceased | Steven Nicholson |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| 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.
Karen Dilks Senior Coroner for the City of Newcastle Upon Tyne REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Head Of Technical Services County Hall Durham County Council Durham DH1 5UQ CORONER lam Karen Dilks, Senior Coroner for the City of Newcastle Upon Tyne 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 http://www. legislation.gov.uk/uksi/2013/1629/parl/7/made INVESTIGATION and INQUEST On the 13" May 2015 | commenced an Investigation into the death of Steven Nicholson, DOB: 24" March 1991, aged 24 years. The Investigation concluded at the end of the Inquest on the 24" March 2016. CIRCUMSTANCES OF THE DEATH Mr Nicholson was the driver of a motor vehicle on the A1018 entry slip road onto the A19 Southbound Seaham, and was continuing, visibility was poor. The A1018 has no street lighting, and an area of standing water approximately 68 meters long by meters wide, had formed on the A1018 beneath the B1404 over bridge. Mr Nicholson had no prior warning of the presence of the water, lack of street lighting and weather conditions hindered his visibility. His vehicle struck the water and he lost control. A collision ensued, in which Mr Nicholson sustained fatal head injuries. The Collision Investigation and Reconstruction concluded that the water pool on the A1018 was the principle cause of the Incident. There were no formal records of any previous incident of flooding on the A1018 within Durham County Council’s reporting system. There was witness evidence including that of the deceased’s family of a number of previous incidents of flooding at this location. CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The absence of appropriate lighting on the A1018 slip road, to assist motorists in identifying and reacting to sudden unexpected hazards. (2) The absence of appropriate signage warning motorists of the risk of flooding on the A1018 slip road. Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE! 8QA Tel 0191 2777280 | Fax 0191 2612952 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by . |, 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 Personsilll MEE | have also sent it to Collision Investigator, a «0 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. Dated 30 March 2016 Signature Senior Coroner for the City of Newcastle Upon Tyne Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QA Tel 0191 2777280 | Fax 0191 2612952
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.
Contact: John Reed Direct Tel: 03000 267454 email: Your ref: Our ref: JR/CB/0516 County Council Gh 7 Ms Karen L Dilks HM Senior Coroner Coroners Court Civic Centre Barras Bridge Newcastle Upon Tyne NE1 8PS 24 MAY 2016 23 May 2016 Dear Ms Dilks Steven Nicholson (Deceased) - Regulation 28 Report Thank you for your letter and report dated 7" April 2016. This was a tragic accident and we wish to express our sincere condolences to Steven Nicholson’s family and friends. We have considered your report carefully and our response is as follows: Absence of Street Lighting The Council provides street lighting in accordance with our Street Lighting Policy which was approved by our Cabinet on 20” November 2013 following extensive public consultation. The majority of consultation responses were supportive of the updated policy. Please find link to the report: http://democracy.durham.gov.uk/ieListDocuments.aspx?Cld=154&MId=7294&Ver=4 The policy is aligned with British Standards and street lighting provision is based on Environmental Zones. This rural slip road falls under Environmental Zone E2 - Area of Low District Brightness. The policy states: “On roads between villages and settlements in Zone E2 areas, lighting will only be provided where there is a known night-time road safety problem that cannot be controlled by other methods such as improvemenis to the carriageway delineation by reflective road studs, carriageway markings and improved signing.” The Inquest confirmed that highway flooding had occurred at this location although we were not aware of any issues prior to this incident. Neighbourhood Services Durham County Council, County Hall, Durham DH1 5UQ Main Telephone (03000) 260 0000 www.durham.gov.uk Page 2 of 2 In accordance with our Street Lighting Policy and best road safety practice we consider that measures to mitigate the risk of future flooding at this location are more appropriate and effective than the installation of street lighting which would only help to illuminate any remaining flooding issue in the hours of darkness. Therefore, we are implementing a scheme to improve the highway drainage at this location by replacing the existing side entry gullies with more effective open top gullies. We expect the works to be complete by the end of July 2016. Absence of Flood Warning Signs The Inquest confirmed that highway flooding had occurred at this location although we were not aware of any issues prior to this incident. If we had received reports of flooding we would have deployed temporary flood warning signs in line with our standard procedures. The investigations and works we have done since the incident to remove the blockages in the drainage system have significantly reduced the risk of flooding going forward. Nevertheless, | have arranged for temporary flood warning signs to be deployed until the above highway drainage improvement works are complete. Flood warning signs are prescribed in the Department for Transport’s traffic sign regulations for temporary use only to warn of occasional hazards. They should be retained only for so long as the hazard continues to exist or is expected to recur in the near future. There is no provision in the Department for Transport’s traffic sign regulations, which we are obliged to follow, for the installation of permanent flood warning signs. Therefore we do not propose to install permanent flood warning signs. | hope that this response reassures you that we have considered your report carefully and are taking appropriate action. Yours sincerely fiz errs mre Head of Technical Services cc , Strategic Highways Manager Highway Inspection & Maintenance Manager , Highway Services Manager t, Corporate Director - Neighbourhood Services itigation Manager
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