Prevention of Future Deaths reports · 2017

Ellie Chappell

Regulation 28 report to prevent future deaths, reference 2017-0198, written 14 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Jun 2017
Reference2017-0198
DeceasedEllie Chappell
CoronerNicola Mundy
Coroner areaSouth Yorkshire (East)
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.

Ms N J Mundy
Senior Coroner for South Yorkshire (East District)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: J

Head of Service, Doncaster MBC, Highways, Regeneration and Environment, Civic
Building, Waterdale, Doncaster

CORONER

lam Ms N J Mundy, Senior Coroner for South Yorkshire (East District)

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 09/01/2017 | commenced an investigation into the death of Ellie Jay Chappell, 21. The
investigation concluded at the end of the inquest on 14 June 2017. The conclusion of the inquest
was Road Traffic Collision. Ellie Jay Chappell died on A614 Selby Road on 2nd January 2017
after hitting a patch of ice whilst driving her motor vehicle which led to loss of control of her
vehicle. The resultant collision led to catastrophic injuries and her immediate death from multiple
traumatic head injuries

CIRCUMSTANCES OF THE DEATH

Ellie Chappell was travelling along the A614 on the morning of the 2™ January 2017 ata
moderate speed well within the prescribed speed limit for that stretch of carriageway. During the
course of negotiating a right-hand bend with a reduced speed commensurate with the icy road
conditions, her vehicle struck a patch of ice causing her vehicle to rotate after which followed
over correction of steering causing her to present the offside of her vehicle to a vehicle travelling
in the opposite direction. She sustained extensive injuries with death being confirmed at the
scene. During the course of the hearing | received evidence from SM of South
Yorkshire Police who had investigated this matter. Part of his investigation included obtaining
data on previous accidents on that stretch of carriageway and END forme me that since
2011 there had been 14 collisions on that stretch of road, four of which included serious injury.
Two of those were on the same bend where Miss Chappell lost control and both these had
slippery road as a factor. Of the others, informed me that five of those recorded
incidents had slippery roads as a factor. He also described to me the location as having the road
sheltered to an extent by surrounding bushes and trees before opening out into an unsheltered
area which would be more prone to ice on the road. Given this information and in particular the
statistics available from 2011, the absence of any warning of any slippery conditions on the
stretch of carriageway and wintery conditions was of some concern. — informed me that
there are steps that can be taken to warn drivers of such impending hazards.

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.

Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 737135 | Fax 01302 736365

The MATTERS OF CONCERN are as follows. —

(1) Given the number of road traffic incidents on this stretch of road and the proportion which
recorded the slippery road as being a factor, | am concerned that the absence of any warning
signs in this vicinity will put drivers at risk of incidents and death in the future.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you fo
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
09 August 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 senta — of um ne to the Chief Coroner and to the following Interested Persons:

| 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 14 June 2017

Signature
Senior Coroner fof Sout

Yorkshire (East District)

Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 737135 | Fax 01302 736365

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 Doncaster Borough Council (PDF)
Te 1WH blae
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Doncaste!

Tel: (01302) 734499

Fax:
Minicom:

Senior Coroner South Yorkshire (East

District) Website: www.doncaster.gov.uk

asinine ha a and Office Our Ref: 0817chappell/LG/SB
rown Cou : .

College Road Your Ref: NJM/rs/tji/52164-2017

DONCASTER Date: 1 August 2017

DN1 3HS

Dear Ms Mundy

Ellie Jay CHAPPELL (Deceased)
DOB: 13.01.1995 — DOD: 02.01.2017

| refer to your Regulation 28 report dated 14 June 2017 and sent to Doncaster MBC,
further to the conclusion of your inquest.

| an ii Head of Service, with responsibilities for Waste and Highways
Infrastructure at the Council.

As you are aware, the Council was not a party to the inquest. Accordingly, on behalf of
the Council, | would like to firstly take the opportunity to express condolences to the family
for the loss they have suffered as a result of this tragic incident.

The Council has noted your concerns regarding the absence of signs to warn of the
potential for slippery road conditions. We are not aware of any previous concerns being
raised by South Yorkshire Police. However, we are always willing to consider matters
relating to road safety. Accordingly, in light of the concerns you have identified, | can
confirm that arrangements are being made for the provision of warning signs, and it is
anticipated that these will be installed by the end of September 2017.

Yours sincerely

CS nth

Head of Service Waste and Highways Infrastructure

Doncaster Council
Civic Office, Waterdale, Doncaster DN1 3BU

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