Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0151, written 21 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2016 |
|---|---|
| Reference | 2016-0151 |
| Deceased | Keith Harper |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:- The Highways Agency 1 | CORONER | am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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 3 December 2015 | commenced an investigation into the death of Keith John Charles Harper aged 59 years. The investigation concluded at the end of the inquest on 18 April 2016. The conclusion of the inquest was that Keith John Charles Harper died as a result of an accident. —-—--| 4 | CIRCUMSTANCES OF THE DEATH On 21 November 2015 Mr Harper was a pedestrian exiting a footpath which crosses the central reservation when he was struck by a Renault Clio which was travelling on the A132 Southmayne in the general direction of Pitsea. He was taken to Broomfield Hospital and then transferred to the Royal London Hospital. He died there on 2 December 2015. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A driver exiting the roundabout has no prior warning of the crossing. From the driver's position the aspect view of the pedestrian/cycle path is limited and the central reservation presents itself as a grassed area. A review should be carried out of features of the pedestrian crossing — warning signs/design/position etc ete (2) The carriageway markings exiting the roundabout have been obscured by resurfacing work and road debris. This work needs to be carried out 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 11" June 2016. |, 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. = 8 | COPIES and PUBLICATION | have sent a copy of my report to the family of Mr Harper and to Essex 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. 9 | 21 April 2016 Caroline Beasley-Murray
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.
Essex County Council 17 JUN 2016 J, PO Box 11 A, County Hall > ae Chelmsford F Essex CM1 1LX Essex County Council Our Ref: H.M Coroner's Office Date: 14 June 2016 County Hall, Sean House Victoria Road South Chelmsford CM1 1QH Dear Mrs Beasley-Murray Inquest into death of Mr Keith John Charles HARPER Thank you for your letter of 21 April 2016 enclosing a notice under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009. This is Essex County Council's formal response under regulation 28 and 29 of the Coroner's (Investigations) Regulations 2013. The matters of concern identified by the Coroner were that: 1. A driver exiting the roundabout has no prior warning of the crossing. From the driver's position the aspect view of the pedestrian/cycle path is limited and the central reservation presents itself as a grassed area. A review should be carried out of features of the pedestrian crossing — warning signs/design/position etc etc. 2. The carriageway markings exiting the roundabout have been obscured by resurfacing work and debris. This work needs to be carried out. The response from Essex County Council is as follows: 1. The crossing area from the central reserve to each footway is an uncontrolled crossing facility, therefore this limits the signing options available to give road users advanced warning of pedestrians crossing at this location. The Traffic Signs and general directions regulations allow the use of ‘other danger ahead’ signage which can be coupled with a ‘pedestrians crossing’ sub-plate. The pedestrian collision data at this site does not support the use of this sign (in the past 10 years there has only been one other collision involving a non-motorised user, this collision wa slight injury collision involving a 12 year old boy pedal cyclist). ben bits EPF-MailMerge-OM1 2. As part of the fatal collision report further actions were sent to Essex Highways SMO3 Maintenance team on the 23/12/2015 indicating that “Following our site investigations we have identified that the lining as part of the segregated cycle facility clearly needs refreshing, as the central segregation line has worn, and the give-way triangles are both missing (either side of the A132 Southmayne) We also identified that the edge of carriageway markings at this location have wom away and we would request that these also be refreshed.” | can confirm that this work has been completed. Yours sincerely Director for Commissioning Transport & Infrastructure Essex County Council Telephone: 03330 136888 Internet: www.essex.gov.uk
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