Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0028, written 31 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2018 |
|---|---|
| Reference | 2018-0028 |
| Deceased | Aaron Nordass-Lacey |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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. Debbie Ward, Chief Executive of Dorset County Council, County Hall, Colliton Park, Dorchester, Dorset, DT1 1XJ 1 | CORONER Iam Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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. 3 | INVESTIGATION and INQUEST On the 20" October 2016, an investigation was commenced into the death of Aaron George Nordass-Lacey, born on the 6" July 1995. The investigation concluded at the end of the Inquest on the 24" January 2018. The Medical Cause of Death was: 1a Head and Chest Injuries The conclusion of the Inquest was that Aaron George Nordass-Lacey died when he fell from his bicycle and was struck by a motor vehicle, but the sequence of events as to how he sustained his injuries is unclear, even on the balance of probabilities. 4 | CIRCUMSTANCES OF THE DEATH On the 13th October 2016, the deceased was riding his father's Corratec X-vert Cross Pedal Cycle along the A35, Barrack Road, Christchurch at Bailey Bridge. He made his way onto the central reservation of that road and fell from his bike towards the carriageway into the path of an oncoming motor vehicle. He sustained unsurvivable injuries to his head and chest and despite being taken to the Royal Bournemouth Hospital, Bournemouth, his death was confirmed there a short time later that day. The sequence of how he sustained his injuries is not clear, whether he hit the ground before he was struck by the car, whether the car struck him before he hit the ground, or whether both occurred at the same time. CORONE! ER 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: The road where the incident occurred that lead to Aaron’s death, the A35 Barrack Road, Christchurch, Dorset is a road which has a speed limit of 30 miles per hour. Evidence was given that people regularly drive at excessive speeds on this road. The location of the incident is near to a school and evidence was given that people, especially school children, do not always use the designated crossing just prior to the junction of Clarendon Road and Barrack Road. Evidence was given that school children often flood out of the school and run into the road. Evidence was given that this was perceived to be a danger and that there could be the death of a person in the future. The placement of barriers along this section of road would assist in reducing the access to the road and encouraging pedestrians to use the crossing to cross the road safely, reducing the potential dangers and risk to life. It was also suggested that a fixed speed camera may assist in regulating the speed of vehicles that use the road. Evidence was also given in relation to the cycle lane along Barrack Road. The cycle lane along Barrack Road heading towards Christchurch is on the footpath and is a shared cycle lane and footpath. The cycle lane comes to an end just before the junction of Clarendon Road and evidence was given by the Collision Reduction Team Manager that the expectation is that when the cycle lane comes to an end, cyclists will cross the road and use the cycle path on the footpath on the other side of the road. Although there is a sign at the end of the cycle lane it is not clear that the expectation is for the cyclist to cross over the road at the crossing. The lack of signage is therefore very confusing and could lead to a further collision. 2. Ihave concerns with regard to the following: The safety of pedestrians and cyclists who use Barrack Road, Christchurch where the incident that led to Aaron’s death occurred. I would therefore request that there is a review of the safety measures in place and consideration is given to the erection of barriers along the pavement and also along the central reservation to discourage pedestrians and cyclists from crossing the road in a dangerous manner. ii. I would also request that a review is undertaken regarding the signage given to cyclists at this location and consideration be given to having a fixed speed camera at this location. 6 | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 28 March 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. 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1) BPS Law LLP, Cardinal House, 20 St Mary’s Parsonage, Manchester, M3 2LY (2) EE Browne Jacobson LLP, 1 Manor Court, Dix’s Field, Exeter, EX1 1UP, on behalf of 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. 3 | Dated Signed OLS —— Rachael C Griffin 31* January 2018
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.
Collision Reduction Team A35 Barrack Road, Christchurch Response report Road Safety Assessment conducted by TMS Consultancy on behalf of Dorset County Council – March 2018 Environment and Economy Directorate Dorset County Council County Hall Colliton Park Dorchester DT1 1XJ March 2018 Road Safety Assessment Response A35 Barrack Road, Christchurch 1. INTRODUCTION 1.1 1.2 1.3 1.4 2. 2.1 This is a report in response to a road safety assessment conducted by TMS Consultancy on behalf of Dorset County Council for the A35 Barrack Road Christchurch between Bailey Roundabout and the junction with Stour Road. The purpose of the assessment was to consider concerns raised by H M Senior Coroner for Dorset Racheal Clare Griffin regarding the inquest into the death of Aaron George Nordass-Lacey. The assessment was conducted by Mark Steventon, LLM, Eng Tech, MIHE, MCIHT, MSoRSA; Senior Road Safety Consultant, TMS Consultancy on Monday 5 March 2018 and the report was completed on 22 March 2018. For completeness, the assessment considered concerns raised by HM Senior Coroner for Dorset and also other potential safety issues on the section of Barrack Road, Christchurch between Bailey Roundabout the junction with Stour Road. Personal injury collision data and traffic speed/flow data was supplied by Dorset County Council’s Collision Reduction Team and was examined as part of the assessment. Safety Issues, Recommendations and Response. Paragraph 7.1 in report by TMS – Risk of accidents involving cyclists travelling too from school – minority of school pupils choosing to cross away from toucan crossing on Barrack Road. Recommendation - Cycle safety training should be delivered at local schools. Response - Cycle safety training ‘Bikeability’ is delivered regularly to school in Christchurch and across the Dorset County Council area. During 2017, six training courses were delivered at Twynham School and two at Christchurch Junior School. Training is planned for 2018 but no dates have been confirmed yet. 2.2 Paragraph 7.2 - Risk of collisions involving cyclists – shell fuel station access. Recommendation - Signs warning of cyclists at the fuel station forecourt have become damaged or misaligned. Response - These signs are not on highway – we will liaise with the filling station to request and arrange that signs are relocated. Recommendation – If practical, the perimeter fence of the electricity sub-station should be realigned and or adjusted to improve inter-visibility between exiting drivers and approaching cyclists. Dorset Highways Michael Potter 22 March 2018 Road Safety Assessment Response A35 Barrack Road, Christchurch Response - This has been deemed to be impractical. Moving the fence would compromise the safety for engineers when accessing the sub-station. 2.3 Paragraph 7.3 – Risk of pull-out collisions at side road junction (Arthur Road) Recommendation – Overhanging hedge should be cut back clear of the junction visibility splay. Response - This hedge is believed to be privately owned. Work is underway to identify and contact the relevant landowner whose responsibility it is to cut back to the hedge as recommended. Landowners have 28 days from receipt of our request to cut back vegetation. 2.4 Paragraph 7.4 – Risk of head-on collisions between cyclists due to dense hedge affect visibility – footway/cycleway at Bailey Roundabout Recommendation – Hedge should be cut back and height reduced. Response - This hedge is believed to be privately owned. Work is underway to identify and contact the relevant landowner whose responsibility it is to cut back to the hedge as recommended. Landowners have 28 days from receipt of our request to cut back vegetation. 2.5 Paragraph 7.5 – Risk of collision involving cyclists – warning sign obscured by overhanging vegetation. Recommendation – Overhanging vegetation should be cut back clear of the warning sign. Response - The overhanging vegetation is believed to be privately owned. Work is underway to identify and contact the relevant landowner whose responsibility it is to cut back to the vegetation as recommended. Landowners have 28 days from receipt of our request to cut back vegetation. 2.6 Paragraph 7.6 – Risk of pedestrian trips and slips (Barrack Road/Stour Road junction) Recommendation – Pavement levels should be adjusted to improve drainage at the crossing points. Response - Nearby drainage gullies will be inspected during week commencing 26 March with any required work ordered accordingly. The pavement level will also be considered during this inspection with work ordered accordingly. Dorset Highways Michael Potter 22 March 2018 Road Safety Assessment Response A35 Barrack Road, Christchurch 2.7 Paragraph 7.7 – Risk of injury to pedestrian – post of local direction sign in footway. Recommendation – Conspicuity of the post should be improved e.g. by attaching a conspicuous coloured band at eye height. Response - Hi-viz coloured band to be added to post on Tuesday 27 March 2018. 2.8 Paragraph 7.8 – Risk of side swipe collisions – Barrack Road north-westbound approach to Bailey Bridge – anomalous deflection arrow in offside lane. Recommendation – The redundant deflection arrow should be removed Response - Works order to remove deflection arrow raised on 22 March 2018 and will be completed as soon as is possible and before the end of April 2018. 2.9 Paragraph 7.9 – Risk of collision between cyclist and pedestrians – Barrack Road toucan crossing Recommendation – The segregated footway/cycleway sign should be removed. The intended safe route for cyclists should be clarified by relocating the remaining ‘end of cycle route’ sign closer to the toucan crossing. Response - The removal of the segregated footway/cycleway sign and relocation of the ‘end of cycle route’ was ordered on 22 March 2018 and will be completed as soon as is possible and before the end of April 2018. I certify that I have reviewed the items raised in the Road Safety Assessment Report and I have given due consideration to each issue raised. I have stated my proposed course of action for each item in this report. Name: Position: Collision Reduction Team Manager Organisation: Dorset Highways, Dorset County Council Signed: Date: 22 March 2018 Dorset Highways 22 March 2018 Road Safety Assessment Response A35 Barrack Road, Christchurch Dorset Highways Michael Potter 22 March 2018
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