Prevention of Future Deaths reports · 2016

Jan Bodnar

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 report29 Apr 2016
Reference2016-0166
DeceasedJan Bodnar
CoronerGraham Danbury
Coroner areaHertfordshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Hertfordshire Council (PDF)
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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