Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0018, written 30 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2017 |
|---|---|
| Reference | 2017-0018 |
| Deceased | David Holman |
| Coroner | Janet Napier |
| Coroner area | Cheshire |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT !S BEING SENT TO: 4. Cheshire East Council, Highways Department 1 CORONER lam Janet Elizabeth Napier, assistant coroner, for the coroner area of Cheshire 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. 3 | INVESTIGATION and INQUEST On 21 July 2016 an investigation was commenced into the death of David Holman aged 38. The investigation concluded at the end of the inquest on 9 January 2017. The conclusion of the inquest was that David Holman died due to a road traffic collision. 4 | CIRCUMSTANCES OF THE DEATH The deceased died instantly on 13 July 2016 when he rode his pedal cycle off the pavement bordering the ‘oad at Plumiey, into the path of a HGV vehicle travelling in the opposite direction. was the collision investigator who gave evidence. 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. It appears that there is no cycle lane there and the road gets very busy, so the footpath was being ridden along. There is a road sign situated just after the area at which the descent into the road is thought to have taken place. One support of this goes into the footpath causing an obstruction. There is also a dip in the kerb edge there. No one seemed to know why it was situated there as there is no field entrance or other opening opposite it. it was thought possible that either one or the other or both of these things could have had some effect in the causation of him leaving the footpath. We should appreciate your consideration of these facts to see if any changes need to be made to less the chance of a similar occurrence happening. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 26 March 2017. |, 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 namely the family of the deceased. | 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: 30 January 2017 Signed: —
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.
>) 2017 — 13 MAR . Cheshire East)! CouncilY Dr. J E Napier Assistant Coroner Westfields Office Of Her Majesty's Coroner Middlewich Road County Of Cheshire SANDBACH West Annexe Cheshire Town Hall, Sankey Street CW11 1HZ Warrington Tel: 01270 686643 Cheshire WA1 10H www.cheshireeast.gov.uk Date: 7" March 2017 OUR REF: J = YOUR REF: Dear Dr.Napier Re: David Holman (Deceased) - Regulation 28 report. Thank you for your letter dated the 30" January 2017 which relates to David Holman (Deceased). | am responding to you on behalf of our Chief Executive, Mike Suarez, who is aware of your letter. | refer to the individual Matters of Concern that are contained within the letter. Regarding the road sign that has a support post situated in the footway; Works are programmed to remove the sign assembly and to relocate it away from the footway. Another area of concern was the dip in the kerb edge/height; Works are programmed to re-kerb this length, this will provide a higher consistent kerb height at this location. The above works are programmed to be undertaken using a lane closure on this very busy road to ensure that safe working practices are observed. With the obligatory permitting of works and the application for road space process it is envisaged that the works will commence in early Spring 2017. It has also been scheduled for the Road Safety Team to make a complete Safety Assessment of this stretch of carriageway with regards to the provision of a cycleway. | trust the above addresses your matters of concern. rsjsincerely All other enquiries 0300 123 5500 www.cheshireeast.gov.uk
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