Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0237, written 22 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 | 22 Sep 2017 |
|---|---|
| Reference | 2017-0237 |
| Deceased | Shahbaz Salim |
| Coroner | Andrew McNamara |
| Coroner area | Nottinghamshire |
| 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: 1. The Chief Executive, Highways England, , Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ 2. , 1 CORONER I am Andrew McNamara, assistant coroner, for the coroner area of Nottinghamshire. 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. 3 INVESTIGATION and INQUEST On 25 January 2016 Miss Mairin Casey, Senior Coroner, commenced an investigation into the death of Shahbaz Salim Bhim and Shana Sutaria. The investigation concluded at the end of the inquest on 21 September 2017. The conclusion following the inquest was that Mr. Bhim’s and Miss. Sutaria’s medical cause of death was: 1. a. Multiple traumatic injury. The summary of the facts was: travelling Southbound At approximately 22.30 on 3 December 2015 the deceased were driver and passenger respectively in a BMW vehicle, registration number along the A46 close to the junction with the A606 at Widmerpool. It was raining heavily. By reason of the presence of standing water in the vicinity of the railway bridge which passes over the A46 and a gulley identified as SBA 14 in a diagram dated 3 February 2016, the vehicle in which the deceased was travelling left the carriageway, passed through a gap in the vehicle restraint barrier and came to rest in Fairham Brook. The drain from gulley number SBA 14 was blocked and unable to cope with the volume of water generated by recent rainfall. It is likely the deceased survived that collision and climbed from the vehicle to the verge alongside the A46. Shortly after the deceased’s vehicle left the carriageway, a Citroen van, registration number came unsighted upon the standing water which caused van. The van left the carriageway and slid along a section of vehicle restraint barrier passing over Fairham Brook. In the course of the van’s uncontrollable slide along the barrier the deceased were struck and sustained fatal injuries. They were pronounced dead at the scene. and travelling at approximately 65 m.p.h. to lose control of the , driven by The conclusion was: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH As above. CORONER’S CONCERNS 5 During the course of the inquest the evidence revealed matters giving rise to concern, namely: 1. The drain SBA 14 was blocked and unable to cope with the volume of water generated by recent rainfall; 1 2. The vehicle restraint barrier at the location of the road traffic collision (Highways England’s location code being X-465224,Y-328926) was and is not continuous. Accordingly: it failed to prevent the vehicle in which the deceased were travelling from leaving the carriageway; and a. b. resulted in Fairham Brook. vehicle being able to mount the barrier passing over 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. – c. The scene of the collision is in a natural ‘bowl’ and that, unless effectively drained, it is a point at which standing water will accumulate during and/or after heavy rainfall; d. The gap in the vehicle restraint barrier (Highways England’s location code X- . 465224,Y-328926) at the entrance to the land owned and/or occupied by (and registered at the Land Registry under title number NT514257) is a hazard to traffic in that it permits vehicles to pass unimpeded from the carriageway. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation has 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 17 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. The families of the late Shahbaz Salim Bhim and the late Shana Sutaria; 2. Highways England, c/o The Government Legal Service; 3. Nottinghamshire Police; 4. AMEC Foster Wheeler; 5. Osborn Abas Hunt (Solicitors for AMEC ), Elizabeth House, 8A Princess Street, Knutsford, WA16 6DD DX: 22952 Knutsford; 6. 7. Head of Claims & Insurance, Virgin Media Services, Mayfair Business Park, Broad Lane, Bradford, BD4 8PW; , AOne+, Valley House, Valley Street North, Darlington, DL1 1TJ; 8. Clyde & Co Claims LLP (Solicitors for AOne+), Chancery Place, 50 Brown Street, Manchester, M2 2JT; 9. 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 22 September 2017 Signed: Andrew McNamara 2 3
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 W england RECEIVED 2 1 NOV 2017 «= = s S J ~ ~ =-~ Highways England Stirling House Osier Drive, Lakeside Court Sherwood Business Park Nottingham NG15 0DS Date: 17/11/2017 Dear Sirs, REGULATION 28 REPORT IN THE CASES OF THE LATE SHAHBAZ BHIM AND SANA SUTRIA, DECEASED On behalf of of Highways England, Please find attached the response from Highways England relating to the above inquest. We have also emailed a copy to the email addresses for If there is anything further we can do to help, please let us know. Kind Regards Red & Green Claims Manager Highways England | Stirling House (Area 7) | Lakeside Court, Osier Drive | Sherwood Business Park | Nottingham | NG15 0DS Web: http://www.hiqhways.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for Nottinghamshire, of The Council House, Old Market Square, Nottingham, NOTTINGHAMSHIRE NG1 2DT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the deaths of Shahbaz BHIM and Shana SUTARIA that concluded on 21 September 2017. HIGHWAYS ENGLAND I am Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. Chief Executive of Highways England Company Limited of CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified are as follows 1 2 a. The scene of the collision is in a natural ‘bowl’ and that, unless effectively drained, it is a point at which standing water will accumulate during and/ or after heavy rainfall; and b. The gap in the vehicle restraint barrier (Highways England’s location code X- 465224,Y-328926) at the entrance to the land owned and/or occupied by (and registered at the Land Registry under title number NT514257) is a hazard to traffic in that it permits vehicles to pass unimpeded from the carriageway. 3 DETAILS OF ACTION TAKEN a. The drainage scheme is progressing as planned through the design and development phases with an estimated start date on the A46 in February 2018. The work will take place over a period of approximately 20 weeks with a planned completion date of June 2018. We are in communication with the family of Mr BHIM (as the agreed contact) to keep the families of Mr BHIM and Miss SUTARIA up-to-date on the progress of the proposed scheme. Dates were provided to Mr BHIM on 10 October 2017 to meet the family members to share the proposed plans, and to visit the site ahead of the start of the works. The visit is planned for 20 November 2017. b. Highways England are in discussions with and his land agent Shouler & Son) regarding the removal of the access to ( the field which will allow us to install a continuous vehicle safety restraint during week commencing barrier. Communication was made with 25 September 2017 immediately following the inquest. As a result, discussions began on the 4 October 2017 and continued on the 23 with October 2017. and his land agent understand the Coroner’s reasons for raising the entrance to the field as a matter of concern and are open to discussions on how the closure of the access can be achieved. Highways England will assess the options to remove the access to the field and close the corresponding gap in the centre reservation. Highways England Land Team will assist in assessing the relevant costs and allow us to place a reasonable monetary value on the land access so that we are able to offer this to existing access. in return for closing the 1 4 DETAILS OF FURTHER ACTION PROPOSED a. The proposed drainage scheme will take into account various assets as well as the drainage to improve this section of the A46 at Widmerpool. The drainage work will include the removal of silt from ditches, repairing / replacing necessary pipework, and the deep cleansing and jetting of pipes, gullies, catch pits and manholes. In addition, further drainage will be installed adjacent to the bottom of the slip road in the vicinity of the railway bridge, in addition to the standard requirements. b. Once an agreement has been reached with we can implement the vehicle restraint barrier alterations in the same timescales as the drainage scheme. This piece of work is being prepared separately to, but in conjunction with, the above drainage scheme as the delivery rests on reaching an agreement with Mr TAYLOR. 5 TIMETABLE FOR ACTION DATE ACTION 10 November 2017 Present the final design pack for the scheme for Highways England internal sign off. 20 November 2017 Meet with the families of Mr BHIM and Miss SUTARIA to share the proposed plans and visit the site. 30 November 2017 Highways England Land Team will detail the relevant value of Feb 2018 - June 2018 the land access to allow continuing discussion with Scheme implemented to address the drainage issues and close the gap. 6 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation in how we go about it. The scheme identified is designed in this light to help to prevent future deaths at this location. 7 COPIES I have sent a copy of my response to Pastures, Melton Mowbray, LEICESTERSHIRE, LE14 3QG (cc. of Turnpike Farm, Hickling , Shouler & Son) as the other party to your Regulation 28 Report (dated 22 September 2017) who has the power to take such action in collaboration with Highways England to prevent future deaths at this location. 8 15 November 2017 Signed: on behalf of , Regional Director, 2
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