Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0422, written 27 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 | 27 Nov 2017 |
|---|---|
| Reference | 2017-0422 |
| Deceased | Ayse Yalcinkaya |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| 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.
Thomas Ralph Osborne Senior Coroner for Milton Keynes REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Jim O'Sullivan, Chief Executive, Highways England Bridge House, 1 Walnut Tree Close , Guildford, GU1 4LZ CORONER | am Thomas Ralph Osborne, Senior Coroner for Milton Keynes 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 29" July 2015 | commenced an investigation into the death of Ayse Yalcinkaya, aged 35. The investigation concluded at the end of the inquest on 22"° November 2017. The conclusion of the inquest was that she died as the result of a Road Traffic Collision. The deceased was driving on the M1 motorway on 29th July 2015 when she was hit by a lorry and died from the resulting multiple injuries. CIRCUMSTANCES OF THE DEATH Ms Yalcinkaya was the driver and sole occupant of a stationary car waiting to exit at Junction 14 of the M1 when a lorry collided with the rear of her car. It appears that the traffic at Junction 14 that was exiting the motorway had come to a standstill. She was pronounced dead at the scene. 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. — (1) | was told by the Police Collision Investigator that the traffic had started queuing on the slip road at Junction 14 into lane one. It was suggested that there was some uncertainty by drivers using the slipway as to which lane they should use and that the signage is not clear. (2) | was also informed that on the most recently build slip roads on other motorways there is now provision for a run off lane to be provided prior to the junction. Perhaps a similar lane could be provided at junction 14 of the M1? 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 gam 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 e The family of the deceased | have also sent it to Thames Valley Police 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 representationsfd aug the coroner, at the time of your response, about the release or the publication of yquy ee by the Chief Coroner. Dated 27" Noye AVIA. if p Signature ft We Senior Coroner for Milton Keynes
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for Milton Keynes, Mr Thomas Osborne of The Civic Offices, 1 Saxon Gate East, Central Milton Keynes MK9 3EJ in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Mrs Ayse Yalcinkaya that concluded on 22 November 2017. 1 HIGHWAYS ENGLAND I am Mr Jim O’Sullivan, Chief Executive of Highways England Company Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified as follows:– a. At the scene of the collision the traffic had started queuing from the slip road at Junction 14 into lane one of the M1. It was suggested by the Police Collision Investigator that there was some uncertainty by drivers using the slipway as to which lane they should use and that the signage is not clear; and b. On the most recently built slip roads on other motorways, the Coroner was informed there is provision for a run-off lane to be provided prior to the junction. Perhaps a similar lane could be provided at Junction 14 of the M1? 3 DETAILS OF ACTION TAKEN a. On 7 December 2018 Highways England commissioned our Asset Support Contractor, Kier, to undertake an investigation report addressing the ‘Matters of Concern’ raised by the Coroner. Highways England received the “Fatal Collision 25 7 15, Investigation Report” from Kier on 15 January 2018. The report included observations of traffic flow, signage, and queueing at M1 Junctions 14 made on a site inspection from Kier Services Highways Division on Tuesday 9 January 2018 between 06:45hrs and 09:30hrs. These findings are being reviewed by the Highways England Asset Development Team to determine what action may be appropriate for further work in 2018/19. This review is to be completed by 31 March 2018. b. The “Fatal Collision 25 7 15, Investigation Report” from Kier made the following comments in relation to paragraph 5 (2) of the Regulation 28 Report; “It is not clear however to the meaning of the Coroner’s comment in item (2) with regards to the ‘run off lane’. This may refer to the lack of hard shoulder provision. On most motorway slip roads the hard shoulder extends the full length of the slip road and terminates at the highway boundary and ‘End of Motorway Regulation’ sign. In this instance on the M1 Junction 14 northbound exit slip, the hard shoulder terminates half way up the slip road. 4 DETAILS OF FURTHER ACTION PROPOSED a. Review findings in the “Fatal Collision 25 7 15, Investigation Report” from Kier. b. Highways England are currently proposing a Smart Motorway Project (All Lane Running) to be implemented between M1 Junction 13 to Junction 16 (Northamptonshire) on both carriageways. The proposal will increase the capacity of the main carriageway to provide an additional running lane by 1 converting the existing hard shoulder to a permanent running lane. The technology delivered as part of the proposed scheme will enable the introduction of variable speed limits throughout the length of the scheme which will regulate the flow and speed of traffic approaching Junction 13 to Junction 16. The proposed scheme will tie into the existing Smart Motorway (Dynamic Hard Shoulder Running) between M1 Junction 10 to Junction 13, and the recently constructed Smart Motorway (All Lane Running) between Junction 16 to Junction 19 to the north. 5 TIMETABLE FOR ACTION ACTION DATE 7 December 2017 Commission Kier to conduct investigation report 15 January 2018 31 March 2018 Summer 2018 Kier Fatal Collision Investigation Report delivered Undertake detailed review of report findings. Programmed start of works for proposed Smart Motorway Project 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 proposed actions identified are designed in this light to help to prevent future deaths at this location. 7 22 January 2018 Signed: Martin Fellows, Regional Director on behalf of Jim O’Sullivan 2
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