Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0383, written 24 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 | 24 Oct 2016 |
|---|---|
| Reference | 2016-0383 |
| Deceased | Joan Green |
| Coroner | Paul Smith |
| Coroner area | Lincolnshire (Central) |
| 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.
HM CORONER Central Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: 1. Director of Highways, Lincolnshire County Council CORONER | am Paul Duncan Smith, Assistant Coroner, for the coroner area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincolnshire, PE23 5JE. 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 INVESTIGATION and INQUEST On 30 March 2015 | commenced an investigation into the death of Joan Lilian Green, aged 77. The investigation concluded at the end of the inquest on 20 October 2016. The conclusion of the inquest was that Mrs Green died as a result of a road traffic collision, the medical cause of death being: 1a. Multiple Injuries CIRCUMSTANCES OF THE DEATH 1 On the 21 March 2015 at approximately 1.00pm Mrs Green was the front seat passenger in an Audi A1 saloon car registered eit | That vehicle was being driven northbound up the A1 Great North Road near the village of Marston, Lincolnshire. The vehicle was being driven by her daughter fi The road comprised a dual carriageway carrying two lanes of traffic in each direction. The National Speed Limit applied to both North and Southbound carriageways. 2 The Audi reached the junction with Toll Bar Road, leading to the village of Marston, which lay to the East. It was the driver's intention to leave the A‘ at that junction , and the vehicle waited in a designated right turn lane, situated to the extreme right hand side of the Northbound dual carriageway, before the driver began to make her turn through a break in the central reservation. 3 The Audi was required to turn across both lanes of the Southbound A11 to reach Toll Bar Road. As it did so it was struck by an HGV travelling in lane 2 of the Southbound carriageway. There was a heavy impact. Mrs Green was killed and her daughter received very severe injuries. 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. — (I) | received evidence that there were no identifiable defects with the junction. Visibility was good, and all signage and road markings, although a little worn, were said to be clear and unambiguous. (Il) | received evidence that although the HGV involved was travelling at 56mph, which was marginally above the maximum permitted speed for that class of vehicle at that time, the limit had since been increased to 6Omph on 6 April 2015 and that the additional speed made little or no difference to the circumstances of this collision. (Ill) | received evidence that in order to assess the likely time taken by the Audi to cross the junction, in the days following this incident, the investigating officer carried out covert surveillance at the junction. During the period of that surveillance, of approximately one hour, he recorded one “near miss” in circumstances identical to the index accident and two further “near miss” incidents. The officer also reported that he observed an HGV waiting for a period of in excess of six minutes prior being able to turn safely across southbound traffic into Toll Bar Road. (IV) | received evidence that whilst there were no defects with the road which could be classed as contributory to this collision, the nature of the junction may have been a contributory factor. It was described as “challenging”. | was told that since 1985 there had been 4 other fatal road traffic collisions at this junction, two of which involved vehicles turning across Southbound traffic. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation has 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 23 December 2016. I, 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 Persons | 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. 24 October 2016 ) PD Smith Assistant Coroner
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.
Highways England Stirling House (Area 7) highways england Lakeside Court, Osier Drive Mr S P G Fisher Sherwood Business Park H.M. Senior Coroner Nottingham Lindum House, 10 Queen Street 79 NG15 ODS a, Spilsby Cc Lincolnshire Ug PE23 5JE ‘ 16" December 2016 Your ref: SPGF/GN 618.15 Dear Mr. Fisher Response to Regulation 28 Report to Prevent Future Deaths — Joan Lilian Green, 21st March 2015. | refer to the above report dated the 24th October 2016, regarding the fatal traffic collision that occurred at the junction of the A1 Great North Road and Toll Bar Road in Lincolnshire. Highways England Company Limited would like to extend sincere condolences to the family of Joan Lilian Green for their sad loss. Following every fatal road traffic collision in the East Midlands Highways England conduct an investigation. The purpose of this investigation is to gather information pertaining to the highway and its environs and to review the collision history at the fatal collision site. An investigation was completed in May 2015 following this collision which | have attached in this response to you. The report concludes that from the initial investigation there does not appear to be any highway related factors. In addition to fatal investigations, Highways England conduct two annual reviews of all collisions recorded on the network in order to prioritise our studies and any subsequent remedial action deemed appropriate. These are our Killed and Serious Injury (KSI) Review and Top 50 Problem Junctions. The KSI Review focusses on links along the network that have recorded two or more fatal and or serious injury collisions within a two km radius. With the Top 50 Problem Junctions focussing on junctions with most personal injury collisions in the previous five years. These studies are conducted every autumn following publication of the latest validated collision data obtained from the Department for Transport. Action to be taken by Highways England The latest KSI Review which is about to be completed, has identified the A1 near Toll Bar Road as a site that requires prioritisation for closer investigation following the fatal at Aap, a vj ~¢ *y INVESTORS SX IN PEOPLE ane Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 20s; collision involving Mrs Green. A study will be completed during the New Year and will consider all collisions that have occurred between Toll Bar Road and Gonerby Moor. The aim of the study will be to identify cost effective remedial measures to reduce or prevent further personal injury collisions in this area. These measures can involve engineering, education or enforcement alongside our colleagues in Lincolnshire Road Safety Partnership. Any action identified following this study will then be added to a bid for funding submitted in the Spring / Summer. The Toll Bar Road junction itself is likely to remain outside the Top 50 Problem Junctions in the latest Top 50 review. : | hope my response addresses the concerns raised in the report. A copy of the results of our study and proposed actions can be provided upon completion. Regards : Yours faithfully A. East Midlands General Manager Enc. Area 7 Fatal Report — A1 Southbound, Marston, Lincolnshire oa Vie iy INVESTORS Sy IN PEOPLE reper EAB, My, <S PO8/, Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363
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