Margaret Pine — PFD report 2017-0239

Date of report	21 Sep 2017
Reference	2017-0239
Deceased	Margaret Pine
Coroner	John Tomalin
Coroner area	Exeter and Greater Devon
Category	Road (Highways Safety) related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1.
Chief Officer for Highways Infrastructure, Development and Waste
Lucombe House
County Hall
Topsham Road
Exeter EX2 4QD

1 CORONER

{am John Geoffrey Tomalin, H.M. Deputy Coroner, for the coroner area of Exeter and
Greater Devon.

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 23" December 2016 | commenced an investigation into the death of Margaret Olive
PINE (Mrs Pine), D.O.B. 5" July 1925, age 91. The investigation concluded on 24m"
August 2017. The conclusion of the inquest was that Mrs Pine died from the injuries she
received as a result of a road traffic collision.

4 | CIRCUMSTANCES OF THE DEATH
On the 17% Mrs Pine was the i in a car driven by
her friend | with another friend in the rear of the car. All
three ladies had been out for the evening to play bingo. They were returning from
Westwood Ho, near Bideford, North Devon, to their homes in Barnstaple at
approximately 9.30pm. The weather conditions were poor, it was raining, very misty and
foggy. The driver of the car, [Z7/77779GM turned left at the Roundswell roundabout off
the A39 with the intention of heading towards the Cedars roundabout between
Sticklepath and Bickington near Barnstaple. This route would have taken her across two
further roundabouts before turning right at the Cedars roundabout. In the fog,

became disorientated and made one wrong tur. Once she found her way back
to the road linking the Roundswell roundabout with the Cedars roundabout she then
proceeded but instead of turning right at the Cedars roundabout she turned right at the
roundabout immediately before the Cedars roundabout. Continuing down this road
without turning left into a residential development the road is closed off by a wall with
which [M[collided. Next to the wall is a cycle path and a footpath but that is not
wide enough for a car to travel down. The police that ation lai the
visibility as very poor and that they were almost adjacent to car when they
found her vehicle. During the course of the Inquest it was identified that the entrance to
this road from the roundabout does not have any sign advising drivers that this is a dead
end, nor indeed does the wall blocking off the road have any form of warning reflective
strips to identify this being a no through road.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concer. 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. —

To avoid the potential for a similar incident in the future | would ask Devon Highways to
consider the erection of signs at the start of the aforementioned road advising drivers
that this was a no through road and at the end of the road which is closed off with a wall,
affixing to that wall some form of reflective signage warning drivers they have reached
the end of the road.

ACTION SHOULD BE TAKEN

in my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 20" November 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:

The —_ of Mrs Pine

| have also sent it to The Devon and Cornwall Constabulary who may find it useful or of
interest.

| 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.

[DATE] ‘Ga B yCORONER}
Lrg Segvemlel 2017 MANA

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 Devon County Council (PDF)

RECEIVED  1  9OCT2017

Devon

County Council

Highways, Infrastructure Development & Waste

Mr J Tomlin
HM Deputy Coroner for Exeter & Greater
Devon
Room 226 Devon County Hall
Topsham Road
EX2 4QD

Lucombe House
County Hall
Topsham Road
Exeter
EX2 4QD

17 October 2017

Dear Mr Tomalin,

Re:  Margaret Olive PINE deceased D.O.D. 20/12/16
Inquest held on 24th August 2017 at County Hall, Exeter
Regulation 28 report

I refer to the Regulation 28 Report dated 22nd September regarding the above Inquest.

In section 5 of the Report you asked for two particular actions to be considered.  I have
attached a sketch which was issued to our contractor ordering works to be carried out in the
suggested locations.  Also attached are the two photographs from their works system
showing completion.

You will, note that we have erected (Site 1) a reflective bollard installed infront of the wall.
Additionally at Site 2 we have erected  an additional No Through Road sign which has been
fixed to the first lighting column after exiting the roundabout, to reinforce the two existing
signs which are attached to the street name plates.

I believe these actions address the matters of concern in your report.

Yours sincerely

Chief Officer, Highways, Infrastructure Development and Waste

www.devon.qov.uk

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