Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0230, written 6 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Sep 2017 |
|---|---|
| Reference | 2017-0230 |
| Deceased | Jeffery Matthews |
| Coroner | Kally Cheema |
| Coroner area | Cumbria |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Highways Department Cumbria County Council CORONER 1 I am Kally Cheema HM Area Coroner for County of Cumbria 2 CORONER’S LEGAL POWERS I 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 3 INVESTIGATION and INQUEST On 20/04/2017 I commenced an investigation into the death of Jeffrey William Matthews born 19th April 1988. The investigation concluded at the end of the inquest 31st August 2017. The conclusion of the inquest was that the deceased Jeffrey William Matthews died as a result of a road traffic collision. 4 CIRCUMSTANCES OF THE DEATH On Sunday 26th March 2017 at about 13.35 hours, the deceased had been riding his motorcycle in a north westerly direction along the C1021 heading towards Great Orton village from the A595, when he collided with the offside of a Nissan Juke travelling in a north easterly direction towards Carlisle along the C2051. The deceased suffered fatal injuries as a result of the collision and was pronounced life extinct at the scene at 14.19 hours. The medical cause of death was recorded as: 1a. Multiple Injuries inconsistent with life 1b. Trauma 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: The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads. The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the ‘Give Way’ sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance. Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection. The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita. Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were; 1. The application of High Friction Surfacing on the north and southbound approached 2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas 3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs. The MATTER OF CONCERN is as follows: (1) The current warning signage on approach to the junction from a north westerly direction is inadequate. (2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility. (3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the HIGHWAYS DEPARTMENT CUMBRIA COUNTY COUNCIL have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st November 2017. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. 2. (Mother of the deceased) (Partner of the deceased). I have also sent it to Cumbria Constabulary Collision Investigation Unit who may find it useful or of interest. I 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. 9 06/09/2017 Kally Cheema HM Area Coroner County of Cumbria
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.
Cumbria County Council County Council Economy & Highways - Cumbria House - 107-117 Botchergate Carlisle - Cumbria - CA1 1RZ E: stephen.hall@cumbria.gov.uk 27 October 2017 Miss Kally Cheema H.M. Area Coroner Cockermouth Register Office Cockermouth Cumbria CA13 9PT Your Ref: 31386/LH Dear Miss Cheema RE: Jeffrey Matthews (Deceased) | refer to your letter dated 6" September containing a copy of the Regulation 28 Report. As you state in your report a study into road traffic collisions over the 3 year period, October 2012 to September 2015, was carried out by Capita and the report was published in May 2016. As a consequence of this report funding was allocated to implement the recommendations in the current financial year, 2017/18. This is standard practice in allocating funds for safety improvements i.e. the study is carried out in one financial year and depending on priorities the recommendations are implemented in the following financial year. The scheme to introduce the high friction surfacing, improved road marking and signage is currently out to consultation with the police, the Parish Council and the local County Councillor and subject to agreement, the measures will be introduced as soon as practicable. The vegetation has already been reduced by the local landowners, presumably as a result of the media coverage of the inquest. Once all measures have been installed a further site visit will be held with the police to see if any amendments need to be made or if any further improvements are required. A statement is made in your letter that the Capita recommendations were not installed due to a lack of resources but they were not installed as by May 2016 the funding had already been allocated for the 2016/17 financial and funding was allocated for the following year, as explained previously. Following the fatal collision in March 2017, a site visit was carried out by staff from the highways department and they immediately actioned the improvement of the white lining. This is in agreement with the police that any defect should be rectified as soon as possible and should not be delayed awaiting the outcome of an investigation or inquest. Serving the people of Cumbria cumbria.gov.uk 2 | hope this provides a satisfactory response to the Regulation 28 Report but if you require any more information or clarification do not hesitate to contact me. Yours sincerely [a Stephen Hall Assistant Director — Highways, Transport & Fleet
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.