Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0418, written 23 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 | 23 Nov 2017 |
|---|---|
| Reference | 2017-0418 |
| Deceased | Jonathan Shaw |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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. Highways Department ’ Bath and North East Somerset 1 CORONER lam Maria Voisin, Senior Coroner, for the area of Avon. : i 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. On 15" August 2017 | commenced an investigation into the death of Jonathan Philip Armstrong SHAW, Aged 44. The investigation concluded at the end of the inquest on 23" November 2017. 3 | INVESTIGATION and INQUEST i The medical cause of death was: la) Multiple injuries The conclusion of the inquest was Road Traffic Collision | 4 | CIRCUMSTANCES OF THE DEATH On 4" August 2017 at around 08:45hrs. Jonathan Shaw was driving his Mini from Chew Magna on the B3130. Whilst negotiating a bend he lost control of his car and it crossed into the opposite side of the carriageway. Another vehicle was travelling in the opposite direction. The Mini collided with the front of this other vehicle. Mr. Shaw died at the scene due to his injuries 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. — At the inquest fF from the Collision Investigation Unit gave evidence. He said that he had been made aware of a couple of incidents at the same location previously. | was also made aware by the family at the inquest of at least 3 or 4 incidents at this same location. | confirmed that he spoke with the Highways Department at Bath and North East Somerset regarding the location of the incident and his findings. He indicated that it was your intention to highlight the need to reduce speed for the bend by adding road signs with a suggestion of a maximum speed for the bend. In addition that you were going to add “slow” painted markings on both approaches to the location of this tragic i incident: | | confirmed that the day before the inquest he had travelled the road in question and that the changes had not been carried out. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 ag" January 2018. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — the family and AXA Insurance (insurers of . 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. 23 November 2017 M.E.Voisin of 4 an een
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