Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0166, written 29 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 | 29 Apr 2016 |
|---|---|
| Reference | 2016-0166 |
| Deceased | Jan Bodnar |
| Coroner | Graham Danbury |
| Coroner area | Hertfordshire |
| 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.
CORONER’S OFFICE AREA OF HERTFORDSHIRE The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES DX: 100702 Hatfield Tel: 01707 292780 Fax: 01707 897399 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr John Woods Chief Executive Hertfordshire County Council Hertfordshire SG13 3DY 1 CORONER | am Graham Rollason Danbury, Assistant Coroner for Hertfordshire 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 13/07/2015 | commenced an investigation into the death of Jan Bodnar, 36 . The investigation concluded at the end of the inquest on 28 April 2016. The conclusion of the inquest was Road Traffic Collision. On 12th July 2015 Jan Bodnar was riding his motorcycle at high speed on the A505 near Ashwell. The motorcycle collided with a car crossing the carriageway causing fatal injuries to Mr Bodnar. The medical cause of death was la Multiple Fractures and Internal Organ Injuries Trauma Ib: Trauma 4 CIRCUMSTANCES OF THE DEATH The deceased was the rider of a motorcycle travelling at high speed along the dual carriageway A505 from Baldock towards Royston. At the junction with Slip End Farm an Audi motor vehicle which had been travelling in the opposite direction on the A505 turned into an opening in the central reservation in order to cross the other carriageway into the farm entrance. The weather was fine and clear. The motor cycle struck the rear of the Audi. The evidence of the Forensic Collision Investigator was that prior to the collision the motorcycle had been travelling at approximately 92 mph in the offside lane of the A505 . His evidence also showed that at the time of the collision the visibility for the driver of the Audi to her left of traffic approaching was severely limited by trees, shrubs and other plant growth on the central reservation. His evidence showed that because of this restriction of visibility the Audi driver would not have been able to see the motorcycle when she moved out of the opening, and that even had the motorcycle's speed been within the 70 mph limit the Audi driver may well not have been able to see the motorcycle as she began to pull out from the central reservation. He measured the visibility available to the Audi driver as 87 metres. He measured the same line of IE visibility, after the growth has been cut, as 270 metres. 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) That the state of the central reservation at this junction was dangerous in that the plant growth severely restricted the view for a driver of traffic approaching from the left. (2) The evidence showed that the growth had been cut back a week or so after this incident, but the risk of danger to motorists will only be avoided if the growth at this junction is regularly cut back. (3) The evidence showed that similar risks may well be present at other similar junctions on this road. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Mr John Woods 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 24 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. COPIES and PUBLICATION | have sent a a of ™ report to the Chief Coroner and to the following Interested Person |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. Dated 29 April 2016 Signature Deputy Coroner for Hertfordshire Pe ee
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.
RECEIVED 23 JUN 2016 UI Hertfordshire BY: Chief Executive’s Office Chief Executive & Director of Environment: John Wood Hertfordshire County Council Mr G R Danbury CH 0238, County Hall Deputy Coroner Hertford SG13 8DE Coroner's Office Fax: The Old Courthouse Tel: PF St Albans Road East Minicon: Zi Hatfield Contact: ii Hertfordshire AL10 OES Vere: —_— Your ref: ay Date: 21 June 2016 Dear Mr Danbury Re: Jan BODNAR, deceased Thank you for your letter dated 29 April 2016 and the attached Regulation 28 Report. | note from the report that you have a number of concerns that you have raised. The County Council takes the safety of road users extremely seriously and in light of these concerns we have undertaken the following; e Cleared the vegetation (tree, shrubs and other plant growth) at the A505 Slip End Farm junction (inside the safety barrier within the central reserve) on 25 and 27 July 2015. e Carried out an assessment of similar junctions on this section of road between Baldock and Royston. This has revealed that of the 11 junctions, 6 require further vegetation clearance over and above what is covered by our cyclical grass cutting maintenance programme. This work is planned to be undertaken in July 2016, subject to weather and other factors outside of our control. e Revised the remit for our highway safety inspectors for this length of road to ensure that vegetation of this nature is identified, enabling corrective action to be programmed. e Revised the maintenance regime for vegetation for this length of road, so that the cutting of trees, shrubs and other plant growth will be carried out in co- ordination with grass cutting on an annual basis. www.hertfordshire.gov.uk Further to the items above, we are reviewing forward visibility requirements at similar junctions on other roads in Hertfordshire. We are using a risk/asset intelligence based approach starting with high speed roads. This assessment will be completed by the end of August 2016. Yours sincerely =» \.S John Wood Chief Executive & Director of Environment www. hertfordshire.gov.uk
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