Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0053, written 22 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2017 |
|---|---|
| Reference | 2017-0053 |
| Deceased | Margaret Jones |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT iS BEING SENT TO:
1. Mr Jim O’Sullivan, Chief Executive, Highways England
2. (Daughter of the Deceased)
3. Avon & Somerset Constabulary
4. Chief Coroner
1 | CORONER
lam Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon
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 13th September 2016 | commenced an investigation into the death of Mrs. Margaret
Joyce Jones age 74 years. The investigation concluded at the end of the inquest on 18th
January 2017. The conclusion of the inquest was that the medical cause of death was
l(a) Traumatic rupture of thoracic aorta. Multiple rib fractures, Fractured pelvis and the
short-form conclusion was that the death was due a ‘Road Traffic Collision’.
4 | CIRCUMSTANCES OF THE DEATH
The circumstances of Mrs. Jones’ death was that on 5th September 2016 she was
driving her Ford Tourneo (Registration [i along Branch Road, Hinton
Charterhouse in the direction of the A36. She was alone in the car at the time. Her
daughter was driving the car ahead with two other occupants. At around 13:24 hours
Mrs. Jones was emerging from the Branch Road junction on to the A36 with the intention
of turning right (south east). Her daughter had just performed the same manoeuvre. As
she commenced the right turn on to the A36 a collision occurred between her vehicle and
a Scania R450 44 tonne articulated lorry travelling north, the driver of the lorry being
unable to avoid the collision.
SSPE
As a result of the collision Mrs. Jones received serious injuries from which she died at the
scene. She was pronounced dead at 14:20 hours. The driver of the lorry was physically
uninjured.
it
During the Inquest | heard evidence from witnesses to the collision as well as from i
of the Collision Investigation Unit, Avon & Somerset Constabulary who {
conducted the collision investigation. In evidence | heard that the weather at the time of
collision was dry, overcast with good visibility. The carriageway surface was mostly dry. |
Junction markings were worn but visible. The high friction coating of the A36 in the i
vicinity of the junction was worn in places. | heard evidence that the speed of the Scania i
R450 immediately before the collision was approximately 35 mph. The speed limit on the |
|
carriageway at the scene of the collision is 60 mph and 50mph for large goods vehicles.
The Ford Tourneo and the Scania R450 were both examined by specialist vehicle
examiners of the Collision Investigation Unit who reported that there were no defects in
either vehicle which would have caused or contributed to the collision. A medical
episode, alcohol and mobile phone use by either driver were not factors in the collision.
During the Inquest | heard evidence that opposite the junction were unauthorised road
side traders making and selling sizeable carved wooden objects. In addition | heard that
Mrs. Jones, who was following her daughter, was anxious not to lose sight of her
daughter as she was unsure of the route. This anxiousness on the part of Mrs. Jones
and the possible momentary distraction due to the traders opposite the junction | found to
be contributory factors to the collision.
During the course of the Inquest | heard evidence from a 3: there had been a
number of road traffic collisions at this junction involving vehicles emerging from Branch
Road, with both the speed of vehicles and traffic density being contributory factors. |
have since been informed of 17 collisions being reported to the Police between 30th
June 2008 and 5th September 2016 including the fatality of Mrs. Jones.
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) Notwithstanding the contribution made to this collision by the factors described above
there have been a number of road traffic collisions at this junction involving drivers
emerging on to the A36.
(2)The speed limit in the section of the A36 either side of Branch Road should be
reduced so as to improve the safety of drivers both those on A36 and those emerging
from Branch Road.
(3) The road signs including carriageway markings should be reviewed and improved so
as to provide greater warning to drivers as to the risk from this junction.
(4) Whilst not factors in this collision appropriate repairs should be made to the high
friction surface and road markings in the vicinity of the junction.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe 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 19th 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
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: EE (O2uchter of the Deceased) as well as Avon & Somerset
Constabulary.
| 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.
22nd February 20 Assistant Coroner
Senate
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 Dr Peter Harrowing The Coroners Court The Courthouse Old Weston Rd Flax Bourton BS48 1UL Dear Dr Harrowing Temple Quay House 2 The Square, Temple Quay Bristol BS1 6HA 30 March 2017 DEATH OF MRS MARGARET JONES-REGULATION “28 REPORT I write regarding your letter of 22 February 2017 to , our Chief Executive Officer, concerning the unfortunate events of 5th September 2016 on the A36 junction with Branch Road that resulted in the tragic death of Mrs Margaret Jones. First of all can I extend my deep sympathy to the family of Mrs Jones. Highways England considers the safety of its customers our number one priority and an incident such as this is felt profoundly within the organisation. In your letter, you refer to four matters of concern including three areas where you consider action should be taken and that Highways England is the organisation that could take action should it be justified. Accident Profile in the locality of the A36/Branch Road Junction In terms of the monitoring of accidents in a given locality, five years of accident data is now considered when assessing a problem location and developing an appropriate intervention, as accident profiles can change over time. The profile in recent years has remained stable since 2012 and improved over that of the years before. It is still considered an accident cluster site, but is ranked number 37 in our priority list in the northern part of our South West region. Please be aware that Highways England has to apply its limited funds in locations where there is an evidenced accident profile and that the intervention progressed must be an appropriate response to accident causation rather than incidents induced by other factors. This is to ensure that the maximum can be achieved in terms of injury savings for the travelling public in the correct locations. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 INVESTORS IN PEOPLE The posted speed limit on the approach to Branch Road and the potential for its reduction The A36 is a strategic road for the movement of goods and people from ports in the south to the large conurbations and motorway network in the north. As such a balance has to be struck between this strategic function and local operation. In the locality of Branch Road it is rural in nature. In order to be effective, posted speed limits need to be intuitive and enforceable. That is to say they need to reflect their surroundings in terms of character and be seen by the travelling public as appropriate and reasonable. In cases where inappropriate speed limits are applied, they are generally not adhered to and in some cases can result in higher speeds as motorists react negatively to something they consider inappropriate. In addition, given the rural locality the Police would find it difficult to enforce a reduced limit here with associated poor compliance. In localities where there have been accidents, we have to be clear that we identify the correct causation and apply an appropriate solution that is based on evidence and the causation of accidents that are being targeted. With reference to this incident it seems the Scania vehicle travelling on the A36, based on the assessment in your letter, was traveling at about 35 mph which is significantly below the posted limit. It does not appear excessive speed was a factor on this occasion and a reduction in the posted limit would be unlikely have to avoided or influenced the unfortunate outcome of the incident of the 5th September 2016. On that basis it would seem inappropriate to reduce the speed limit in a locality where it is unlikely to be adhered to and have any positive effect. Signing and road markings on the approach to Branch Road A scheme was completed on 24th November 2015 at Branch Road with the aim of raising the visibility of the Branch Road junction. It comprised the following elements: (cid:127) The introduction of a double white line system to prohibit motorists overtaking (cid:127) The replacement of two existing “BEND AHEAD” warning signs to also include a junction warning sign on yellow backing boards to raise awareness and the visual profile of the junction for approaching motorists. (cid:127) SLOW road markings adjacent to the signs. (cid:127) Red surfacing on the right-turn facilities to’discourage encroachment on to them. (cid:127) New direction signing on passive posts to improve driver awareness and reduce the potential for sudden changes in direction in the locality of the junction. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 t \ INVESTORS I N PEOPLE 1 The validation of STATS 19 accident data takes some time to come through to us. We do not have a full year of validated accident data after implementation of the scheme in order to determine its effectiveness or otherwise. Normally we undertake Road Safety Audit (RSA) 4a and 4b at 12 months and 36 months respectively to monitor the effect of a scheme on the accident profile. Appropriate Repairs to High Friction Surfacing Our maintenance interventions are made on the basis of priority and safety. We have had our pavement specialists inspect the junction recently. The wear of the HFS is immediately opposite the junction, caused by tyre friction associated with vehicles turning off of the A36 and not in the braking zone for approaching vehicles. It is not currently safety critical and it can reasonably be assumed that at the time of the accident was in better condition that it is now. Following monitoring, a localised temporary repair was recently implemented and a permanent replacement scheme for part of the HFS is being progressed through the normal prioritized value management process. Conclusion In summary, the A36 is an evolved rural route and we have in place a realistic speed limit and applied what engineering measures are possible to make the travelling public aware of the risks that they are approaching. The road surface, specifically the HFS, while showing signs of wear is still fit for purpose and what wear there is can be considered normal and adjacent to the junction rather than in the braking zone. It will of course be monitored and overtime be replaced during our normal cycle of renewals. On that basis I consider we have implemented appropriate repairs and management regimes. Other factors influenced the tragic events of 5th September 2016 and these were not associated with the physics of the A36 or Branch Road. You have found that the anxiousness of Mrs Jones not to lose sight of her daughter and the possible momentary distraction due to traders opposite the junction were contributory factors to the collision. Given the factors that colluded against Mrs Jones it is difficult to identify any engineering measures that would have prevented this tragedy that were not already in place. We are of course not complacent and will continue to monitor the locality as we do with our entire network. If the situation changes here we would look to act within our constraints and in an appropriate manner Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 INVESTORS I N PEOPLE V Z I trust this information is of use. Yours sincerely Team Leader South West Operations Division - Growth & Improvement Team Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ Highways England Company Limited registered In England and Wales number 09346363 INVESTORS , N PEOPLE
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