Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0436, written 6 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jul 2017 |
|---|---|
| Reference | 2017-0436 |
| Deceased | Cameron Chadwick |
| Coroner | Jennifer Leeming |
| Coroner area | Manchester (West) |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| 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.
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. The Chief Executive, Wigan Council, Wigan Life Centre, The Wiend, Wigan WNi 1YN CORONER I am M Jennifer Leeming, HM Senior Coroner for the Coroner Area of Manchester West. 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. INVESTIGATION and INQUEST On the 9" of February 2017 I commenced an investigation into the death of Cameron Chadwick, 15 years, born 28" January 2002. The investigation concluded at the end of the Inquest on 5” July 2017. The medical cause of death was:- Ta Multiple Injuries The conclusion of the Inquest was Cameron Chadwick died of a Road Traffic Accident. CIRCUMSTANCES OF THE DEATH On the 7" of February 2017 Cameron Chadwick was riding a motorcycle on Helveyllyn Road,Wigan when he lost control of the vehicle and fell from it, sustaining injuries that led to his death. 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. During the Inquest evidence was heard that:- i. Evidence was given at the Inquest that there was a pothole in the carriageway near to where the accident that caused Cameron Chadwick's death occurred. An officer of Wigan Council informed the Court that a pothole that was 40mm or more deep should be repaired. A Police Officer gave evidence that whilst he could not fully guarantee the exactness of his measurement the pothole was 45mm deep at the time of this accident. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that 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 31% August 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. EE (mother), ne 2. EE (Father) [-— 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. Dated Signed . 6" July 2017 M Jennifér Leeming, HM Senior Coronér
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.
I 4fcCEJ¥ED 2 5 AUG 2017 Wigan0 Council DH/AW MJL/YD/00604-2017 Date: 111,1August 2017 Professor M J Leeming HM Senior Coroner Her Majesty’s Coroner Paderborn House Howell Croft North Bolton BL1 1QY Dear Professor Leeming Cameron Chadwick - Deceased Regulation 28 Report to Prevent Future Deaths Thank you for your correspondence dated 6th July 2017 relating to the inquest into the unfortunate death of Cameron Chadwick and the Regulation 28 notice that has been served to Wigan Council. I have now been able to investigate the background into this matter and I would like to advise you as follows. Having considered the content of the Regulation 28 - Coroners Report, we have now carried out a number of actions, in particular relating to points 5.6 and 7 which are actions directed to Wigan Council. I have outlined below the specific interventions and actions that we have taken, in response to each of these points. Action Point 5.1.i - Coroners Concerns I can confirm that a Technical Officer (Highways and Streetworks) and a Technical Design Officer (Highways) from the Highway Asset Management Team, who are experienced in carrying out highway safety inspections, attended the location of the incident at Helveyllyn Road, Norley Hall, Wigan on 6th July 2017. The purpose of this site visit was to establish the depth of the carriageway pothole. In the police report (exhibit DJH 2- point 19) the police officer gave evidence that the pothole was 4.5cm (45mm) deep at its lowest point at the time of the accident. www.wigan.gov.uk Confident Place, Confident People. However, I can confirm that the actual depth of the carriageway pothole as measured on site by the two council officers (6lh July 2017) was 36mm deep at its deepest point. I have attached a photograph referenced H1 as proof of this measurement. Action Point 6 - Action Should Be Taken I can confirm that Wigan Council has in place a Highway Safety Inspection Policy for its highway network. All highways are subject to regular safety inspections by competent highway inspectors. Any safety defects found during those inspections giving rise to a real source of dangers to reasonable users would have been subject to repair within certain timescales dependent on the degree of the danger. However, in line with best practice and from the Regulation 28 - Coroner’s Report advising us this incident, the highway asset management service has exercised their discretion to carry out a repair, although it did not actually meet the Council’s highway intervention level for a safety defect. For recording purposes I can advise that a temporary repair to the carriageway pothole was actioned 6th July 2017. This temporary repair was followed up with a permanent one on 17th July 2017. I have attached a photograph referenced H2 as evidence of this repair. Action Point 7 - Your Response Please accept this letter as our confirmation that we have complied with your report and provided details of the actions/dates we have taken to comply with your Regulation 28 request. I trust that the above is satisfactory to you, but should you require any further information relating the above, please let me know and we will do our best to help. Yours sincerely Chief Executive & J =>! Ililllllfl F %\7 fa. *5;i AM ■ '■ - ■ f l&f.V j “ ■ ?;Wj «/}y A:>/<’?Af ',:: x t 4* f * r f r P . ? (cid:127) ; . ■ ' ■ i f r’ ♦ x>J < 5 ...» '' > * r j (cid:127) < £KMRIV V i A" ‘ ’A‘\< * *(cid:127) ■ / # i w < ’■ r. j- .y f l ■ ■ - ■ " ■J’'" ' (cid:127) . '■ j - . ■ ■'- ■ ■/'» w , - w & . ,7. \ , ' (cid:127) ' . ' . . . . ' A - ' ' '■' F ,: ': A '■ / '■< ■ * ,fl- ■ A y ■ 'r ': . ■ fl '■ ;-.. : (cid:127) ‘ f, ' ' ■■ :<-i' %& fl . r * / ' > - ;* x '. ■ ' '.4$ II ! L:, * (cid:127) f ■ . . . . . . . . ■ ■ V . - . . ■ ; ' (cid:127) “ . . . ■ ? I . " ~ . - - L . ; ■ ■ ■ < , J ■ ■ ■ ' > . . / ■ ' ■ ■ . 7 ' < - > (cid:127) . . 5 ■ . > . y . ■ , ■ ■ (cid:127) - . _ / . . . (cid:127) ' ■ ■
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