Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0175, written 6 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 May 2016 |
|---|---|
| Reference | 2016-0175 |
| Deceased | Lee Nauman |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire Western |
| 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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT
IN THE MATTER OF:
HH SSS
The Inquest Touching the Death of Lee James Nauman
Regulation 28: Action to Prevent Future Deaths
rar
] THIS REPORT IS BEING SENT TO:
1
Bradford MDC -
CORONER
Martin Fleming HM Senior Coroner for West Yorkshire Western
CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 20 of the Coroners
(Investigations) Regulations 2013
|
INVESTIGATION and INQUEST
On 22/12/15 I opened an inquest into the death of Lee James Nauman
who, at the date of his death, was aged 24 years old. The inquest was
resumed and concluded on 4/5/16
I found that the cause of death to be: -
la. Head Injuries
larrived at a conclusion of Road Traffic Accident
4 | CIRCUMSTANCES OF THE DEATH
On 16/12/15 at approximately 7.15am, Lee James Nauman left for work
from his home address on his Yamaha 125 motorcycle. He drove along
Lee Lane, a single carriageway two-way road with no markings dividing
the opposing the lanes. It is accessed from the B6146 Cottingley Moor
Road and eventually leads to M & M Yorkshire Stone at Bank Top. He
travelled towards Bank Top until he reached Moor View Crescent, which
forms a 90-degreeT-junction to the left before a short row of houses
associated with Moor View Drive. It was as he travelled along Lee Lane
in the direction of Cottingley Moor Drive that he lost control of his
motorcycle and slid diagonally across the road directly into the path of an
oncoming vehicle, causing him to sustain fatal head injuries. The court
heard evidence to suggest that he may have been speeding up to the
collision, notwithstanding the poor road and weather conditions.
Although there was some evidence to suggest that he may have taken
cannabis the previous evening, it was thought not to be conclusive.
RT3589 1
CORONER’S CONCERNS
During the course of the inquest I heard evidence from rr
{Collision Investigator), who conducted an examination of the road
surface approximately 32.4 metres to the Cottingley side of the collision
scene and found that the extreme nearside edge of the road surface was
broken and crumbling away, leaving a pothole approximately 4 metres
long and 5ccm deep encroaching onto the road surface approximately 0.6
metres from the extreme nearside edge. He also found an area of leaf and
soil debris upon the road surface 14 metres in length across the whole
width of the road encompassing the pothole. Although there was no
evidence to suggest that this caused or contributed to the loss of control
of the motorcycle, was unable to discount the possibility that it
may have had a contributory effect.
The MATTER OF CONCERN is as follows. —
e To review the road conditions at the location and to consider the
appropriateness of remedial action.
rr | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that Bradford MDC has the power to take such action.
|
=
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 | COPIES
Thave sent a copy of this report to:
-
HEE (Collision Investigator)
a
° 7
e Chief Coroner
CEP,
RT3589 2
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.
Page 1 of 4 Sent: 04 July 2016 17:29 Subject: RE: Regulation 28: Action to Prevent Future Deaths Attachments: Photo 1.pdf; Photo 2.pdf; Photo 3.pdf; Photo 4.pdf Dear Ms Allen Under Regulation 29 (Response to a report on action to prevent other deaths) this email contains notification of the actions taken by the Council in response to the inquiry recommendations. Following an inspection of Lee Lane, some work was ordered on w/c 16 May to address issued identified during a site inspection of the issues highlighted in the Regulation 28 notification. These works consist of pothole filling and patching, primarily along the edge of carriageway at various locations between Cottingley Moor Road and Bank Top. Photo 1 shows the existing surface on the uphill approach to Moor View Crescent which is on the left, on the brow of the hill, the point at which the collision took place. Photo 2 shows a view slightly futher back towards Cottingley Moor Road, with a private drive on the left. The RTA occurred on Wednesday 16th December 2015. The first of the December 2015 floods occurred over the weekend 12th and 13th. Our on-site inspections indicate that gravel wash-out from Moor View Crescent (Photo 3) is still evident at the edge of carriageway on the opposite side of Lee Lane (Photo 4). It is likely that gravel would also have been washed down the slope in the direction of Cottingley Moor Road. I realise that the inquest has now concluded, but it would it appear that the motorcyclist, on approaching the slight left hand bend towards the brow of the hill at Moor View Crescent, slid on loose gravel, rather than hitting the potholes at/beyond the edge of the carriageway. Contact was made with the Council’s Cleansing team to determine whether they had received any requests for road sweeping along Lee Lane immediately following the weekend floods/ RTA. Their records only indicate attendance for some fly tipping. However, it would appear that the gravel has since been removed, either by routine/cyclic sweeping or possibly by those local residents responsible for the maintenance of Moor View Crescent. I trust the above sets out sufficiently the actions arising from the Regulation 28 notification. Yours sincerely Transportation Development Manager Planning, Transportation & Highways Service 4th Floor Britannia House, Hall Ings, Bradford, BD1 1HX City of Bradford Metropolitan District Council Department of Regeneration 05/07/2016
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