Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0380, written 11 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Oct 2016 |
|---|---|
| Reference | 2016-0380 |
| Deceased | Vichal Tonpradit |
| Coroner | Geoffrey Sullivan |
| 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 Jim O'Sullivan
Chief Executive
Highways England
Federated House
London Road
Dorking
Surrey
RH4 18Z
CORONER
| am Geoffrey Sullivan, Senior 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:/Awww. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Avww. legislation.gov.uk/uksi/2013/1629/part/7/made
3 INVESTIGATION and INQUEST
On the 11" November 2015 | commenced an investigation into the death of Vichai Tonpradit.
The investigation concluded at the end of the inquest on 11 October 2016.
The conclusion of the inquest was a Narrative Verdict: Road Traffic Collision contributed to by
the road layout. The raised section of the tarmac presents a hazard to road users, and a solid
white line left from the previous road layout running into the kerb is potentially confusing.
CIRCUMSTANCES OF THE DEATH
On the 10th November 2015 at around 19:28hrs Vichai Tonpradit was riding his motorcycle
northbound on the A1(M) in the nearside lane towards Junction 6 at Welwyn. When he
attempted to cross the hatched area of the exit to rejoin the main carriageway he struck a raised
section of tarmac separating the slip road from the main carriageway. He fell to the road surface
and as he rose was struck by a heavy goods vehicle and then by a small hatchback travelling in
the northbound carriageway. Vichai Tonpradit was confirmed deceased at the scene at 19:4/hrs
by a paramedic. Multiple Traumatic Injuries
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) The raised section of the tarmac separating the slip road from the main carriageway on the
A1(M) approaching Junction 6 northbound is potentially hazardous.
(2} At the same location, the visual marking (solid white line) from the previous road layout is
potentially confusing
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
06 December 2016. 1, 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
Lhave sent a copy of my report to the Chief Coroner and to the following Interested Persons
the deceased’s niece; Mr John Wood, Chief Executive of Hertfordshire County
Council,
{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 11 October 2016
Signature
Senior Coroner for Her
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for Hertfordshire, Mr Geoffrey Sullivan of The Old Courthouse St Albans Road East, Hatfield, Hertfordshire AL10 0ES in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Mr Vichai Tonpradit that concluded on 11 October 2016. 1 HIGHWAYS ENGLAND I am Mr Jim O’Sullivan, Chief Executive of Highways England Company Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY GU1 4LZ. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified as follows:– a. The raised section of the tarmac separating the slip road from the main carriageway on the A1(M) approaching Junction 6 northbound is potentially hazardous; and b. At the same location, the visual marking (solid white line) from the previous road layout is potentially confusing. 3 DETAILS OF ACTION TAKEN a. The raised section of kerb separating the off slip road from the main carriageway on the A1(M) at Junction 6 northbound is addressed at point 6a. below. b. Having reviewed the road markings at the location it would appear that since the incident on 10 November 2015 the road marking referred to was covered over by applying a bituminous material to obscure the redundant solid white line and this is no longer visible. 4 DETAILS OF FURTHER ACTION PROPOSED The government announced as part of the Roads Investment Strategy 2015-2020 the proposal for a Smart Motorway for the A1(M) Junction 6 to 8. The introduction of the Smart Motorway scheme for this section of the A1(M) would alter the existing road layout at Junction 6 northbound and southbound. The preferred operating model for smart motorways is “All Lane Running”. This means the existing hard shoulder would be converted into a traffic lane providing three lanes for traffic with the addition of regular refuge areas in place of the hard shoulder for emergency use. As part of this scheme Highways England will assess a wide range of information about the road to establish the nature of any current issues along this section. This will assist us in developing an outline design concept and determine the Smart Motorway operating system best suited to this section of road. The start of works is currently programmed for March 2020. 5 TIMETABLE FOR ACTION Date Action March 2020 Start of works on the Smart Motorway – All Lane Running scheme on the A1(M) Junction 6 to 8 1 6 EXPLANATION AS TO WHY NO ACTION IS PROPOSED a. Highways England (as far as we have been able to ascertain) was not a party to the inquest hearing on 11 October 2016. The ‘raised section of tarmac’ identified as a matter of concern by the Senior Coroner, is a specifically designed and installed section of raised kerbing to separate the off slip road from the main carriageway at Junction 6 of the A1(M) northbound. The extension of the kerbing separating the slip road and main carriageway was introduced as part of a ‘pinch point’ scheme in 2015 to reduce congestion on this part of the strategic road network. The scheme was designed and constructed to the specified standards laid down in the Design Manual for Roads and Bridges (DMRB) and these standards remain current today. In addition, the scheme was subject to the Road Safety Audit process in accordance with the requirements of HD19/15 as directed by the DMRB Volume 5 Section 2. 7 SAFETY OF ROAD USERS We apologise unreservedly for the lack of response on behalf of Highways England to the Senior Coroner’s Regulation 28 Report dated 12 October 2016. The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation in how we go about it. The action we have taken and plan to take in the near future is designed in this light to help to prevent future deaths on our network. 8 05 October 2018 Signed: , Asset Development Manager on behalf of 2
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