Prevention of Future Deaths reports · 2016

Beverley Siddall

Regulation 28 report to prevent future deaths, reference 2016-0230, written 24 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 May 2016
Reference2016-0230
DeceasedBeverley Siddall
CoronerEmma Carlyon
Coroner areaCornwall
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.

Beverley Lawford John Siddall

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: Corporate Director for
Economy, Enterprise and Environment, Cornwall Council,

1.
CORONER

| am Dr Carlyon the Senior Coroner for the area of Cornwall an the Isles of Scilly

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.

[
INVESTIGATION and INQUEST

Beverley Siddall died on 8" August 2015 and an investigation was opened on 21°
August 2015 and an Inquest on the 11" February 2016. The inquest hearing took
place at Truro Municipal Buildings on 16" May 2016.

CIRCUMSTANCES OF THE DEATH

Beverley Siddall was driving his blue Fiat Panda car registration number Ra

along the A3075 in the direction of Newquay on 7" August 2015. At around
22.40 pm, after a series of bends in the road at Perranwell, near Goonhavern,
he failed to negotiate the last bend and his car left the road and dropped down
four feet and entered a field, where the car was seen to bounce until it came to
rest in a nearby river .He was not wearing a seat belt and the airbags deployed.
As a result of this together with the collision, he suffered multiple injuries. He
was attended by a first-aider and paramedics and transferred to the Royal
Cornwall Hospital, Treliske, Truro where he was recognized dead at 03.09 on 8h
August 2015 as a result of his injuries. It was not clear whether there was any
reason why Mr Siddall failed to negotiate the bend.

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. —

That two witnesses to the traffic collision noted in evidence that they had seen evidence
of a good number of cars leave the A3075 road at Cosy Cottage, Perranwell at the same
point as Mr Siddall. The police Collision Investigator at inquest, noted when he went to
survey the scene there was another car present that had come off the road which had
nothing to do with Mr Siddall’s collision. There was concern at inquest that the road
layout, or safety notices and/or barriers in place, were not adequate and that this section

of road should be reviewed with the view to reducing the risk of cars leaving the road at
this point.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation or arm’s length company e.g. Cormac] have the power to
take such action.

To review this section of road to address the issue of car leaving the road at the end of
the series of bends on the A2075 at Cosy cottage

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19" July 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 copy of my report to the Chief Coroner and to the following Interested
PI | 70 350 sent ito the
Devon and Cornwall Serious Collison Investigation Unit who may find it useful or of
interest.

| 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.

[DATE] [SIGNED BY CORONER]

24.05.2016 Cyzabeth Gree Cor lyon

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 Cornwall Council (PDF)
one and all ‘onen hag all

CORNWALL
COUNCIL

Dr E Carlyon
Coroner for Cornwall

The New Lodge Your ref:

Newquay Road ; My ref:

Penmount po Date: 13 July 2016
Truro

TR4 9AA

Dear Dr Carlyon

A3075 Lambourne Mill Bend, Perranzabuloe

Thank you for your letter dated 24 May and attached report with respect to a road
traffic collision on the above highway.

The Council has now thoroughly investigated the circumstances of this unfortunate
incident and as we did not attend the inquest have made efforts to speak to the
Senior Investigation Officer and Collision Investigator. We have, of course, also
examined and reviewed all the accident data kept by the Council.

After careful consideration of the facts resulting from our investigations, advice from
the Council’s lead Road Safety Auditor, the content of your report and the geometry of
this particular highway, the Council has concluded that any works at this site such as
crash barriers or Cornish hedging are as likely to cause injury to occupants of any
vehicle that fails to negotiate the bends as to protect them from it. We note that in
this instance the head injuries to Mr Siddall resulted partly from his failure to wear a
seat belt rather than from an excessively violent impact. Indeed, the impact itself was
relatively minor and Mr Siddall’s vehicle continued to drive over the field largely
undamaged until it came to rest at the stream. Had a solid barrier been at the foot of
the hill, the likely deceleration would have been greater not lesser than Mr Siddall
experienced, and it may very well have resulted in exactly the same unfortunate
outcome.

Whilst we are aware of anecdotal reports of vehicles ending up in the field (‘damage-
only’ accidents), only one other accident has been formally reported in the last five
years at this location (a minor injury collision). Given the severity of this bend at the
foot of a long, steep hill on a principal road, this is an unexpectedly low accident and
injury rate. The lack of injury may well be attributable to the comparatively benign
path into the field beyond. Consequently, blocking this with a solid fence or hedge
could result either in a more severe direct impact if drivers lose control, or their
redirection into the path of oncoming traffic with the potential for further injury.

Cornwall Council, The Exchange
< 5 County Hall, Truro, Cornwall, TR1 3AY
nt

INVESTOR Px PEOPLE Tel: 0300 1234 100 www.cornwall.gov.uk

This would only be worthwhile if the accident record itself warranted this compromise,
and it does not appear to do so at the present time; we would be in danger of creating
greater numbers of injuries than the measure might prevent.

In 2003/4 the council carried out a Local Safety Scheme on this bend, erecting large
yellow-backed chevrons and widening and hatching the bend. This has proven to be
very effective in terms of the accident record, and the bend has not been on the
Council's list of accident cluster sites since this work was undertaken. In recent years
the speed limit has also been reduced to 40mph (from 60mph), although this is
somewhat academic given the nature of the corner. There is little further that could be
done to ensure drivers are aware of the severity of the bend, and to help them remain
on the road.

In light of the above, therefore, the Council does not believe it is suitable to introduce
solid restraints to the outside of the bend. The Council will, however, continue to
monitor the site and others like it in conjunction with the police.

I thank you for bringing this matter to our attention and giving us an opportunity to
review the site.

Yours sin¢erel

Corporate Director
Economy, Enterprise and Environment

Tel
Ea cr

Cornwall Council, The Exchange
C) County Hall, Truro, Cornwall, TRL 3AY
> Ne

INVESTOR IN PEOPLE Tel: 0300 1234 100 www.cornwall.gov.uk

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