Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0185, written 13 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 | 13 May 2016 |
|---|---|
| Reference | 2016-0185 |
| Deceased | Harold Davies |
| Coroner | Maria Mulrennan |
| Coroner area | Nottinghamshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HIGHWAYS ENGLAND 2. A‐ONE+ 3. NOTTINGHAMSHIRE COUNTY COUNCIL 1. CORONER I am Maria Mulrennan, assistant coroner, for the coroner area of Nottinghamshire. 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INVESTIGATION AND INQUEST On the 16 November 2015 I commenced an investigation into the death of Harold James Davies, then aged 91. The investigation concluded at the end of the inquest on the 25 April 2016. The conclusion of the inquest was Road Traffic Collision, the medical cause of death was multiple injuries 4. CIRCUMSTANCES OF DEATH 1. On the evening of the 8 November 2015 Harold James Davies was driving his Volvo motorcar along Station Road, Collingham, Nottinghamshire towards its junction with the A.46 dual carriageway. 2. From the surrounding evidence, it is likely that Mr Davies was intending to cross over the northbound carriageway of the A.46 and turn right into the southbound carriageway towards Newark. 3. Mr Davies did not stop at the junction or give way to oncoming traffic in the northbound carriageway, and collided with a Jaguar motorcar travelling in lane 2. 4. Subsequent investigation of the vehicles involved in the collision and of the collision scene itself concluded: (a) There were no mechanical or electrical defects in either vehicle that would have caused or contributed to the collision (b) Neither driver were under the influence of alcohol or other intoxicants (c) The weather conditions were reasonable (d) Both lighting an visibility were goo (e) The carriageways were free of any defects or contaminants that might have caused or contributed to the collision (f) The warning signs on the approach to the junction were clear and unobstructed. 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: 1. Although the current road layout and existing safety provisions did not cause or contribute to the particular circumstances of this collision, I am concerned that this is the 3rd fatality at this junction since 2010. The 2 most recent fatalities in January 2014 and November 2015 involving, vehicles emerging from Station Road into the northbound carriageway. 2. Highways England and their maintenance contractor A‐One+ have undertaken an extensive risk assessment of the junction and there is a proposal to undertake the following remedial safety work: (a) vehicle activated signs on both carriageways of the A.46 to alert oncoming traffic of the presence of vehicles at the junction waiting to join or cross the carriageways (b) the installation of slim line bollards at the Station Road junction (c) appropriate demarcation of the central reservation/turning area. 3. Evidence was given at the inquest that there is no date for the approval of funding or the commencement of the remedial safety work. 4. The national speed limit on Station Road on its approach to the junction with the A.46 is 60mph. The SCIO gave evidence that additional warning signs and a possible reduction in speed limit on the approach would provide additional safety for drivers who were unfamiliar with the Station Road and its approach to the junction. Nottinghamshire Police has offered to meet with Nottinghamshire County Council, the authority responsible for the maintenance of Station Road, and undertake a risk assessment. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you, respectively have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report namely by 8 July 2016. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taking, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interest Person, . I have also sent it to Nottinghamshire Police, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish each or both in a complete or redacted 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 publication of your response by the Chief Coroner. 9. DATE: 13 MAY 2016
3 responses 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.
A-one+ Unit 7, Evo Park, Little Oak Drive, Sherwood Business Park, Nottingham, NG15 0EB 25th May 2016 FAO HM Assistant Coroner, Mrs Maria Mulrennan Office and Main Court Council House Old Market Square NOTTINGHAM NG1 2DT By post and email: Dear Mrs. Mulrennan, Re: Inquest touching the death of Harold Davies We confirm safe receipt of your 'Prevent Future Death' report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 dated 13th May 2006. We note your concerns and respond as follows. As you know, A-one+ is contracted by Highways England to manage the highway assets within 'Area 7' which includes the accident locus. As confirmed by our at the recent Inquest, A-one+ has made a number of recommendations to Highways England with a view to improving the safety of the junction. These recommendations are helpfully set out at section 5 of your report. Unfortunately, A-one+ has taken this matter as far as it can and it is now the responsibility of Highways England to secure funding for the improvements. A-one+ does not have the authority to progress this matter any further, but will fully support and co- operate with Highways England and the authorities in all cases. Furthermore, A-one+'s contract with Highways England regarding the management of 'Area 7' is due to expire on 1st July 2016. From this date, A-one+ will have no responsibility for the management of the highway assets at the accident locus. This will be managed in-house by Highways England. As you quite rightly noted at the Inquest, your concerns in relation to the approach from Station Road to the junction with the A46 is the sole responsibility of Nottinghamshire County Council. Whilst A-one+ has taken this matter as far as it can, it has agreed to a meeting with Nottinghamshire Police, Nottinghamshire County Council and Highways England. Please be assured that A-one+ is not seeking to be obstructive in any way, it is simply the responsibility of Highways England and Nottinghamshire County Council to address the concerns raised within your report. A-one+ is a joint venture between Halcrow Group Limited, Vineyard House, 44 Brook Green, London, W6 7BY - Registration No.3415971, Colas Ltd, Wallage Lane, Rowfant, Crawley, West Sussex, RH10 4NF - Registration No. 2644726, and Costain Ltd, Costain House, Vanwall Business Park, Maidenhead, Berkshire, SL6 4UB – Registration No. 1393773 In the meantime, should you require any further information or assistance, please do not hesitate to contact our Yours faithfully, Area 7 General Manager
Response to Regulation 28 Report – Harold James Davies Following receipt of a Regulation 28 report from HM Assistant Coroner Maria Mulrennan on the 13th May 2016 after the inquest into the death of Harold James Davies held on the 25th April 2016, I offer the following information. I called together representatives of Highway England and Nottinghamshire County Council to attend a meeting at Nottinghamshire Police Lakeside Court building on the 2nd June 2016. Those present were, , Road Casualty Reduction Manager, Nottinghamshire Police (Chair) (HD) , Team Manager Accident Investigation of Nottinghamshire County Council. (GC) , Asset Manager, Highways England. (RK) , Senior Insurance Assistant, AOne +. (GC) Ian Malkin, Highways England. (IM) Each partner had previously received a copy of the report from HD and the report was then discussed at length. RK reported that as stated at the inquest an accident remedial scheme had been designed by AOne + and RK was now trying to obtain the necessary funding from Highways England to get it put into the work programme. The scheme did not meet the criteria for funding from the ‘Minor Safety Improvement Fund so RK had escalated the funding request to senior manager level. Partners then looked in detail at the proposed remedial scheme which consisted of interactive signs on the approach to the junction, central area marked out clearer and improved signage. GC had investigated Station Road which was the County Council road that approached the junction (the junction being on the A46 which is the responsibility of Highways England) and had decided there was no merit in changing the speed limit on this road. GC’s separate report detailing this decision is attached. All partners agreed with this decision as the speed of entry into the junction at all three fatal collisions was extremely slow if not stationary. RK said that she would do everything she could to secure the funding for the scheme so that it could be on the ground at the location asap but this could take some time. The meeting was then adjourned to give RK time to speak to the senior managers at Highways England to secure the funding that was needed. On the 23rd June 2016 HD received an email from RK which stated the following, Since we met on 2nd June I have been liaising with colleagues to identify funding for the junction improvements described under 5.2 of the report. As discussed, the funding mechanisms under the Roads Investment Strategy have changed and we no longer have Local Network Management Schemes (LNMS) funding. The new funding is called Designated Funds and we are currently exploring various avenues to gain the approval we require to deliver the scheme at the junction of Station Road. The matter has been escalated to Senior Managers and discussed at the various finance meetings. I will continue to press this matter, if our Investment Decision Committee (IDC) do sign off the required funds we will aim to deliver the scheme within the next year. We sent a crew out on the 4th June to clear the vegetation around the Station Road junction to improve the visibility in all directions. Summary A meeting has taken place with all highway representatives pertinent to this case and the report has been fully discussed. All parties agree that the best way forward to prevent further deaths which was the purpose of the Regulation 28 report issued by HM Coroner would be for the accident remedial scheme designed by AOne + to be implemented by the Highways Agency. As soon as funds are identified the scheme will go ahead and hopefully this will be within the next year.
Nottinghamshire County Council response to Coroner Regulation 28 Report following Inquest into the death of Harold James Davies The fatal accident and two previous fatal accidents occurred at the junction of the Trunk Road A46 and Station Road Collingham. Since the incidents happened on the Trunk Road, which are the responsibility of Highways England, the County Council has not carried out investigations on these individual incidents, or the group of accidents. From what we understand, two of the three accidents, including that of Mr Davies, involve drivers emerging from the side road, Station Road, onto the A46. They were in collision with vehicles on the A46. In such cases it is important to distinguish between restart and overshoot type accidents. In a restart, drivers are aware of the junction and as a result slow or stop, but then fail to give way, or misjudge main road traffic speed. An overshoot occurs where a driver is unaware of the junction or doesn’t see it in time, and then enters the main road without pausing. It is understood that the two accidents were most likely restarts, Mr Davies was apparently indicating to turn right, suggesting he knew he was approaching the junction. It is not usually effective to try to affect this type of accident by measures on the side road approach. The measures proposed by Highways England on the main road A46 are more appropriate. However if further investigations by Highways England and/or their agents were to conclude that enhanced advanced give way signing were appropriate, Nottinghamshire County Council would of course be happy to co-operate with Highways England in consideration of installation of such measures within its highway boundary along Station Road. Station Road is derestricted, that is, its speed limit is 60mph which is the national speed limit for such roads in the absence of any other posted limit. The situation is very common there are many thousands of miles of these derestricted roads in rural areas. The 60mph is an absolute upper limit, and drivers have to adapt their speed to suit the road layout and conditions as they find them throughout their journey. Therefore when approaching the junction with the A46, drivers on Station Road will slow and adapt their speed to allow them to negotiate the bend on the approach, and slow appropriately for the junction. We have no evidence that excessively high speed is occurring on this approach, or that it is leading to reports of injury accidents on Station Road. We also understand that approach speed is not a significant contributory factor in the accidents at the A46 junction. Even if it were the case that speeds approaching the junction were too high, simply lowering the speed limit would not be an effective way of addressing the problem. It is well known from research that, in the absence of the threat of Police enforcement, a driver will adopt what they deem to be a safe speed for the road, with only limited reference to the speed limit. National guidance suggests that limits should reflect the speed at which drivers are travelling, rather than the other way round, and unrealistically low limits are discouraged. A lowered speed limit would require a legal order to be brought into force, which would involve amongst other things a lengthy consultation process. The consequent delay in progressing the proposed Highways England improvement scheme, and the costs of signing and implementation of a speed limit, are therefore not appropriate given the arguable benefits. Team Manager Accident Investigation Nottinghamshire County Council 06 June 2016
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