Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0393, written 10 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2017 |
|---|---|
| Reference | 2017-0393 |
| Deceased | Graeme Flatman |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| 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.
Karen Dilks Senior Coroner for the City of Newcastle Upon Tyne REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Katherine Fairclough, Chief Executive Cumbria County Council, Cumbria House 117 Botchergate Carlisle CA1 1RD CORONER | am Karen Dilks, Senior Coroner for the City of Newcastle Upon Tyne 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 the 21 March 2017 | commenced an Investigation into the death of Graeme Stafford Flatman. The Investigation concluded at the end of the Inquest on the 24 October 2017. The conclusion of the Inquest was Accidental Death. CIRCUMSTANCES OF THE DEATH On the 11 March 2017, Mr Flatman, who was an experienced pedal cyclist was riding his pedal cycle on the A593 Oxen Fell, Skelwith, Ambleside. Whilst travelling down a steep incline, he collided with a Nissan Qashqai motor vehicle travelling in the opposite direction. The road layout prevented Mr Flatman and the motor vehicle driver from identifying each others presence on the road. Mr Flatman suffered fatal injuries in the said collision. CORONER’S CONCERNS The A593 is a scenic cross country road with a speed limit of 60 miles per hour. No signage is present within the area in which the collision occurred, warning road users of the severity of the toad gradient or the limitations upon visibility. Coroners concerns are: The MATTERS OF CONCERN are as follows. — 1. The absence of appropriate signage to warn road users approaching severe incline/decline on the road ahead 2. The absence of appropriate signage warning of visibility limitations on the road ahead 3. The appropriateness of a 60 mile per hour speed limit on a single carriageway road, with one lane in each direction containing numerous straight sections, bends and gradient changes Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NEI 8QA. Tel 0191 2777280 | Fax 0191 2612952 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Katherine Fairclough, Chief Executive, Cumbria County Council 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 5 January 2018. |, 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 Famil i ion Investigator, who may find it useful or of interest. lam 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 10 November 2017 Signature Senior Coroner forthe City of Newcastle Upon Tyne Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NEI 8QA Fel 0191 2777280 | Fax 0191 2612952
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 Economy & Highways (cid:127) Cumbria House (cid:127) 107-117 Botchergate Carlisle (cid:127) Cumbria (cid:127) CA1 1RZ Cumbn County Council 6 December 2017 Karen L Dilks HM Senior Coroner Coroner’s Court Civic Centre Barras Bridge Newcastle-Upon-Tyne NE1 8QH Dear Ms Dilks 0 7 DEC 2017 Re: Regulation 28 - Graeme Stafford Flatman (Inquest 24/10/2017) I refer to your letter dated 10th November containing a copy of the report pursuant to Regulation 28 of the Coroner’s Investigations and Regulations 2013. As you state in the report the A593 is a typical scenic route in the Lake District National Park with a speed limit of 60 miles per hour. The route links Ambleside in the north to Broughton-in-Furness to the south going through Skelwith Bridge and Coniston. Along the route at various locations there are signs to warn road users of bends, road narrowings, steep inclines and cyclists and in addition road markings have been introduced to advise drivers to slow down in advance of a hazard ahead. As a result of the Regulation 28 report we will visit the site, with the police if possible, and review the signage at the collision location. It is hoped to organise this site meeting early in the New Year and install any measures before the end of March. The speed limit of 60 mph is typical for the rural roads in the County but this will also be looked at with regard its appropriateness. Any changes to this will require a consultation and legal process which will take at least 6 months to complete. As this road is within the National Park we do try to keep sign clutter to a minimum and this will be a factor in considering new signs and a new speed limit but road safety will be the major consideration. I 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 Assistant Director - Highways, Transport & Fleet Serving the people of Cumbria cumbria.gov.uk
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