Prevention of Future Deaths reports · 2017

Luke Mumford

Regulation 28 report to prevent future deaths, reference 2017-0047, written 23 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Feb 2017
Reference2017-0047
DeceasedLuke Mumford
CoronerKate Thomas
Coroner areaMid Kent and Medway
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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Kent County Council

CORONER

| am Kate Thomas Assistant Coroner, for the coroner area of Mid Kent and Medway

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

On 29" of November 2016 | commenced an investigation into the death of Luke
Mumford, aged 20. The investigation concluded at the end of the inquest on the 15" of
February 2017. The conclusion of the inquest was Road Traffic Collision.

| CIRCUMSTANCES OF THE DEATH

| CORONER'S CONCERNS

At approximately 17.30 on the 23" of November 2016, Luke Mumford was driving his
motor car along Pilgrim's Way, north of Eccles, Kent when he left the carriageway,
traversed up a 3 metre bank, struck a tree and came to rest 13 metres further on in a
field. He sustained extensive head injuries from which he died at the scene. He had not
consumed any alcohol or drugs and the reason why he had left the carriageway could
not be ascertained.

At the point at which Mr Mumford left the carriageway, Pilgrim's Way is a dual
carriageway but more accurately should be described as a narrow single carriageway in
each direction separated by a foliage verge. It is unlit at night and passes through a rural
area and is comparable to a country lane. The speed limit however is 70 mph.

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 nature of the road is such that it is unsafe to drive at 70 mph in that
i) The carriageway is very narrow
ii) The road is unlit at night

iti) The road is not bordered by any kerb or pavement but rather hedgerows
and trees

ly) At Inquest the evidence of a Police Pursuit Driver and Accident Collision
Investigator was that they had felt unsafe traversing the road above 50
mph.

‘| ACTION SHOULD BE TAKEN

tn my opinion action should be taken to prevent future deaths and | believe 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 20" April 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

I have se port to the Chief Coroner and to the following Interested
Persons : Next of Kin )

| have also sent it to Chief Constable for Kent 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.

23° February 2017

Kate Thomas
Assistant Coroner
| Mid Kent and Medway

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 Kent County Council (PDF)
Kent

County

Council
kent.gov.uk

Highways, Transportation & Waste

Coroners Court Officer Invicta House
County Hall
Sent by email: MKMadmin@kent.gov.uk Maidstone

Kent ME14 1XX

Tel: 03000 418181
Our Ref: 15814447
Date: 04 April 2017

Re: Coroners Regulation 28 Report

Kent County Council makes this response formerly to the Coroners’ Regulation 28 report
following the incident on Pilgrims Way, north of Eccles, Kent on 29" November 2016.

We are always extremely saddened to hear of fatalities on Kent's roads, particularly so
when the deceased was so young and when it appears to be unexplained why the driver
left the carriageway in this way.

The road is narrow and unlit and is bordered by hedgerows and trees. In its context as a
‘de-restricted’ dual carriageway the speed limit is 7Omph, however it should be noted that
the speed limit is the absolute maximum speed - it doesn’t mean it is safe to drive at this
speed in all conditions. Notwithstanding this, in response to the incident and the very
clear coroner recommendation, Kent County Council will be programming a scheme to
reduce the speed limit of the road to 50mph.

In order to ensure that introducing a speed limit of 50mph does not lead to an increase in
safety concerns, Kent County Council will also investigate a Crash Remedial Measure to
seek to improve the ‘safety’ of this dual carriageway; this may include additional signs,
lines and barriers although the exact composition will be determined by a full and proper
study. We must be mindful when introducing a 50mph speed limit that the presence of
‘repeater signs’ does not encourage high speeds, as there may be sections of this road
that may not be safe to drive at that speed, especially for an inexperienced driver.

Once again | would like to offer my heartfelt sympathy to the family of the deceased.

Yours sincerely,

= ; =. Transportation & Waste

Related reports

Other reports by Kate Thomas

See all →

More reports categorised “Road (Highways Safety) related deaths”

See all →

Track Road (Highways Safety) related deaths

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.