Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0090, written 20 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2017 |
|---|---|
| Reference | 2017-0090 |
| Deceased | Ralph Brazier |
| Coroner | Christopher Sutton-Mattocks |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF;
‘The Inquest Touching the Death of Ralph lan Brazier
A Regulation 28 Report- Action to Prevent Future Deaths
(_] THis REPORT IS BEING SENT TO:
The Chief Executive, Surrey County Council
County Hall
Penrhyn Road
Kingston upon Thames
KT 2DN
1 CORONER
Mr Christopher Sutton-Mattocks, HM Assistant Coroner for Surrey
3 | CORONER'S LEGAL POWERS
I ntake this report undér paragraph 7(1) of Schedule 5 to the Coroners and
Justice Act 2009.
ee
3 | INVESTIGATION and INQUEST
The inquest into the death of Mr Brazier was opened on 4 March 2016 and was
resumed and concluded on 2 March 2017. The cause of death was:
Fracture dislocation of the upper cervical spine.
Tho inquest concluded with a narrative conclusion.
4 | CIRCUMSTANCES OF THE DEATH
Mr Brazier, a 52 year old man, was cycling along with 6 other riders as part of
the Twickenham Cycling Club on 1 March 2016, They were cycling in the
“through and off” formation whereby cyclists ride in two parallel lines rotating
positions, As the group approached Weybridge on the A317 Mr Brazier was
cycling on the inside of the through and off formation at approximately 20 mph.
The cyclists would ride 0,75m-1m from the side of the kerb depending on the
road surface. At a point on the A317, just past the junction with Hamm Court
Road, the front wheel of Mr Brazier’s cycle hit a pot hole next to the drainage
gully cover, His cycle was stopped instantly and he was thrown forwards
landing on the road in front of the drain.
The pot hole and gully covex bad been brought to the attention of Surrey County
Council (SCC) after having been reported by a local resident on 25 January
2016. On the same day the SCC website reported the kerbside surface breaking
up around the drain gully. The gully appeared to be collapsing and it was classed
category 2 by a SCC Highways Inspector.
On 28 January 2016 the gully was temporarily repaired by a Kier Plc team and
immediate response was placed on the defect by the Highways inspector. On 12
February 2016 a permanent repair was made by the Kier Ple team whereby a
new grating was fitted and the gully frame was re-fitted, On 25 February 2016,
an inspection by a highways inspector for SCC, showed that the
permanent repair had sunken and it was scheduled Priority 2 by ME for 5
working days, Had it been marked as Priority 2+ it would have been scheduled
for repair within a much shorter time period.
A highway inspector from 8CC would see the defect, assess the travelling
public, the risk of harm, or damage to the highway user and then classify it, All
road users are taken into account when inspecting a road however a cycle path
would be inspected differently in respect of cyclists with a different defect
categorisation. For a highway the defect would have to be greater than 75mm
for a 2+ defect, whereas for a designated cycle lane the defect would have to be
only in excess of 40n0m.
The planned date of repair was 2 March 2016, within the period of the P2
classification but one day after Mr Brazier’s death,
5 : CORONER’S CONCERNS
Having heard evidence from a number of members of Suxtey County Council, I
am concermied that insufficient consideration is taken by the Council of the
increasing number of cyclists on their highways, particular in relation to the
categorisation of defects on the highway, I am particularly concerned that
designated cycle lanes are given higher priority relating to a defect than a
highway, despite the high number of cyclists using the highway rather than
cycle lanes with closer proxitulty to traffic including heavy goods vehicles.
The MATTERS OF CONCERN are:
- Surrey County Council has failed to take into sufficient account the fact
that cyclists use the highways as well as the cycle lanes in their priority
categotisations.
- That the great number of cyclists, and the risks to them using the
highways, particularly the nearside section, are not specifically
considered when Surrey County Council are assessing the highways for
repair.
Re-consideration should be given to whether auy steps, including changes to the
categorisation of highway defects in light of the greater use of public highways
by cyclists, can be taken to address the above concerns.
ACTION SHOULD BE TAKEN
tn my opinion action should be taken to prevent future deaths and I believe that
the people listed in paragraph one above have the power to take such action.
abr
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I may
| extend that period on request,
Your response must contain details of action taken or proposed to be taken,
setting out the timetable for such action. Otherwise you must explain why no
action is proposed.
COPIES
{have sent a copy of this report to the following:
j |
2. Kier Pie
3. The Chief Coroner
“| Signed:
CHRISTOPHER SUTTON-MATTOCKS Way bt AL ot
DATED this 23rd day of March 2017
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.
Surrey County Council’s response to the Regulation 28 Report On 27" March 2017 Mr Christopher Sutton-Mattocks, H.M. Assistant Coroner for Surrey, issued a report under paragraph 7(1) of Schedule 5 to the Coroners and Justice Act 2009 following the inquest touching the death of Ralph lan Brazier (“the inquest”). The Coroner’s concerns are as follows: “Having heard evidence from a number of members of Surrey County Council, Lam concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. | am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles. “The MATTERS OF CONCERN are: e Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as cycle lanes in their priority categorisations. e That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair. “Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.” This is the response of Surrey County Council to that report and to the coroner’s concerns set out therein. Surrey County Council (“SCC”), as the highway authority, is responsible for the upkeep and maintenance of public highways within Surrey. The total length of the highway road network is approximately 3,000 miles across which there are approximately 175 miles of designated cycle routes. On average 70,000 reported defects on the highway are repaired each year. SCC has published and applies a highway policy which includes a detailed inspection regime of the network and measurement criteria for the assessment and prioritisation of defects in the highway. The current Highway Policy can be found at https://www.surreycc.gov.uk/roads-and- transport/roads-and-transport-policies-plans-and-consultations/roads-and-transport-policies-and- plans/highway-safety-inspections-standards-and-procedures In formulating its highways policy SCC works in close partnership with Kier plc, which is responsible for undertaking the highway repairs. The aim is to maintain a policy that is compliant with the National Code of Practice and which enables the effective management of risk to the safety of all highway users across the whole Surrey network. The Department of Transport publishes a Code of Practice which provides guidance and recommendations to highway authorities in the formulation of their highways policies. The Code of Practice distinguishes types of highway, including the carriageway for general use (vehicular, pedestrian and cycle) and cycle routes. The Code acknowledges that cycle routes can form part of the carriageway or be separate from it. The Code of Practice recognises that different factors and criteria apply to the assessment of the condition of the carriageway to that of designated cycle routes. SCC is satisfied that its current highways policy complies with the requirements set out in the Code of Practice. In particular the imposition of more stringent defect criteria on designated cycle routes is entirely in accordance with the advice and guidance provided by the Department of Transport. The latest revision of the Code of Practice was published in October 2016 and in accordance with the revision of this national document SCC has begun a review of its highway policy. As part of this review SCC will also consider the Coroner’s concerns and if and to what extent the inspection regime, including defect assessment and categorisation, should be amended, This will include for further analysis of the number of cyclists and differing use of the highway network by cyclists in Surrey. To allow for sufficient consideration of the revised national Code of Practice the authority has two years to make any amendments to their policies following its publication. On this basis the latest timescale for implementation of any changes to our Highway Policy will be September 2018. In relation to the matter of assessment, highway inspectors, when assessing any defect in the highway, are required not only to apply the defect criteria set out in the policy but also to consider the particular circumstances of the locus including the potential danger created by the defect to all road users, cyclists as well as vehicle drivers. Cyclists are entitled to, and do, use all parts of Surrey’s road network. Highway Inspectors take this into account when assessing potential defects. the Highway inspector who identified the defect scrutinised at the inquest, gave evidence that he took into account the potential dangers to cyclists when he categorised the defect. SCC is satisfied tha ssessment fully complied with its highway policy. Inspector training requirements are set out in the Code of Practice and SCC is satisfied that it is compliant in this regard, To enhance the existing training regime SCC are preparing additional training for the highway inspectors in relation to the risk assessment for vulnerable users, which includes for cyclists. This additional training will be completed by the end of August 2017, Ongoing training requirements will be further reviewed following the completion of the review of the highway policy. SCC are aware of the increased use of the network by cyclists within Surrey as a result of the London Olympics and Ride London and have implemented various measures to improve cycling safety in general. For example, SCC provide national standard Bikeability cycle training which teaches cyclists to ride away from the kerb; to avoid hazards, to improve their visibility to vehicle drivers, and to encourage vehicles to overtake as they would do other vehicles. SCC have also utilised the DriveSMART initiative to engage with sports cyclists using Facebook and recently carried out a cycling safety campaign which included messages to cyclists to ride away from the kerb and also messages to motorists to give cyclists room. The following link provides more information: hitp://www.drivesmartsurrey.org.uk/media-and-publicity-campaigns/cycling/
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