Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0452, written 16 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2016 |
|---|---|
| Reference | 2016-0452 |
| Deceased | Exauce Paoulen |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: Highways Department, Birmingham City Council 1 CORONER I am Emma Brown Area Coroner for Birmingham and Solihull 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 08/07/2016 I commenced an investigation into the death of Exauce Mbiyi Paoulen. The investigation concluded at the end of an inquest on 13th December 2016. The conclusion of the inquest was Road traffic collision. 4 CIRCUMSTANCES OF THE DEATH Exauce passed away at 15:59 on the 29th June 2016 at the Birmingham Children’s Hospital as a result of injuries he sustained when he was involved in a road traffic collision on Grove Lane, Handsworth on the 24th June 2016. Exauce ran out from next to parked cars on the west side of Grove Lane passing behind a car travelling north in the nearside lane and was struck by a vehicle proceeding in the southbound lane that was travelling at something in the region of 32mph.. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1(a) NEUROLOGICAL FAILURE 1 (b) TRAUMATIC BRAIN INJURY (OPERATED) AND HYPOXIC BRAIN INJURY (OUT OF HOSPITAL CARDIC ARREST) 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. – In the area of Grove Lane bordering Handsworth Park children and adults often cross the road to access the park gates. The road has a speed limit of 30mph and there is not a pedestrian crossing near the park gates. Opposite Handsworth Park there is a parking bay on the west side of Grove Lane that is frequently parked up and obscures the view for drivers proceeding along Grove Lane of pedestrians, particularly children, approaching the edge of the road. There have been several other serious accidents involving pedestrians crossing the road in the vicinity in the past 2 years. This evidence suggests that the speed along this section of road in conjunction with the parking bay creates a risk to pedestrians crossing the road. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th February 2017. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Exauce’s parents, West Midlands Police and to the local safeguarding board. I 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. 9 16/12/2016 Emma Brown Area Coroner Birmingham & Solihull Districts
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.
EXCELLENCE + 5 15] CUSTOMER SERVICE Birmingham 4 | City Counell 10 January 2017 Emma Brown Area Coroner, Birmingham & Solihull Districts Coroner's Court 50 Newton Street Birmingham B4 6NE Dear Ms Brown Exauce Mbiyi Paoulen (deceased) Grove Lane - Handsworth Thank you for your letter and report dated 16 December 2016 regarding the above. My service has worked closely with your office and the West Midlands Police over many years to follow the outcome of inquests and carry out improvements to the highway in order to reduce the potential for the reoccurrence of serious road collisions. The Council works towards reducing road traffic collision casualties across the City by means of education, enforcement and engineering through a programme of highway improvement works. Our Local Safety Scheme Programme team monitors all reported road traffic collisions that lead to death or serious injury. The locations with the most significant history of incidents are selected for detailed assessment and the development of proposals aimed at reducing the likelihood of further incidents. These proposals are prioritised and form the basis of our Local Safety Scheme Capital Programme. Prior to receiving your report Grove Lane had been identified for assessment through this monitoring system and initial investigations are being undertaken to develop a local safety scheme at this location. The scope of these investigations will incorporate the suggestions contained in your report. A scheme proposal will be developed in consultation with the local residents, Ward Councillors and West Midlands Police. Following consultation, formal approval will be sought to secure funding to implement the scheme in line with the City’s Governance procedures. It is my intention to implement a scheme in the financial year 2017/18 but would hope that if consultation goes well this could be as early as June /July 2017. To summarise, and to meet the requirements of our formal response to your report: e Birmingham City Council will take action to develop and consult on road safety improvements along Grove Lane. Economy Directorate — Highways and Infrastructure P.O. Box 37 Telephone: PF 1 Lancaster Circus Queensway Birmingham e-mail: B4 7DQ Internet: http:/Awww. birmingham.gov.uk/highways e The implementation of the scheme will be programmed for 2017/18 with an aspiration that the works will be complete by the end of July 2017. | hope this is helpful. Yours-sincerely ) Assistant Director — Highways & Infrastructure
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.