Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0098, written 9 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Apr 2018 |
|---|---|
| Reference | 2018-0098 |
| Deceased | Darryl Souza |
| Coroner | Hassan Shah |
| Coroner area | Northamptonshire |
| 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.
REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: Northamptonshire Highways — Northamptonshire County Council Highways Agency CORONER !am Hassan Shah, Assistant Coroner for the coroner area of Northampton. 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. INVESTIGATION and INQUEST On the 25/10/2017 | commenced an inquest into the death of Darryl Alfred Wayne Rego SOUZA aged 26. The investigation concluded at the end of the inquest on 23/03/2018. The conclusion was that Mr Souza died as a result of a road traffic collision. | CIRCUMSTANCES OF THE DEATH Mr Souza died on Saturday 7" October 2017 at the crossroad junction of Naseby Road and Longhold Road, Clipston, Northamptonshire as a result of fatal chest injuries sustained when the motorcycle he was riding was involved in a collision with a Mini motor vehicle. Mr Souza had approached the scene on Longhold Road travelling from Sibbertoft. On Mr Souza’s approach, at a point 100m from the crossroads, the road negotiates a slight left hand curve and at the same location 2 warning signs are located at the near and the off side of the road with attached boards underneath that state "Give Way 100 Yards”. The road then straightens and it is possible to see straight over the crossroads through to the Kelmarsh road. Just prior to the junction, a “Give Way’ sign is sited on the nearside grass verge. Faded, but visible give way lines then control the junction. The Mini motor vehicle had been travelling on Naseby Road heading from Clipston towards Naseby. Approaching the scene from Clipston, the main Naseby Road leaves the village exiting the 30 mph zone and entering the 60 mph zone that is applicable up to and including the site of the accident which is 600m away. The road travels straight for a short distance before it then curves to the left round a slight bend. Once round the bend the road i is straight and descends a slight decline towards the scene of the incident. As the scene is approached, the Naseby Road can be seen turning to the left up ahead and prior to this left hand bend, a crossroads warning sign mounted on a high visibility yellow board is situated to the near side of the road with a plate mounted underneath it stating “110 yards”. “Slow’ is painted on the road surface adjacent to the road and although faded is visible. A further conventional cross road sign is situated towards the later end of the curve on the grass verge the near side footpath and again, “Slow’, is painted on the road surface adjacent to this sign. Mr Souza was riding a sports motor cycle which meant he had a low position in the road. There were hedges on his approach which obscured his view of Naseby Road ahead. There were windows of increased visibility but these closed down the closer that he got to the junction. Mr Souza had slowed to 10-15 mph then almost came to a stop at the crossroads. At the junction, the maximum unhindered view of Naseby Road to his left was 79m. A vehicle travelling at the applicable speed limit (60 mph) would cover 79m in 2.9 seconds. The Forensic Collision Investigator concluded it was... “possible that when Darryl emerged from Longhold Road, the driver of the Mini would not have had time to take any avoiding action”... Mr Souza sustained serious chest injuries having collided with the A-pillar of the Mini and sadly succumbed to his injuries at the scene. There was no evidence of dangerous or excess speed from either driver or rider. There were no defects in either vehicle that could have contributed to the accident. The weather and road conditions were favourable. 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 could 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. Paragraphs 6.11 — 6.14 of the Forensic Collision Investigator's report is set out below. 6.11 There is no doubt that the visibility at this junction is compromised by the road geography and as such high visibility “Give Way” signs and crossroads signs together with “SLOW painted on the road surface serve to hightant the location of the crossroads and the need to take care. 6.12 In view if the visibility at this junction and after reviewing the Collision statistics at this Junction there are to be some improvements carried out. 6.13 These improvements include renewing the signing particularly from the Sibbertoft direction and noise or rumble strips to be placed on the road again from the Sibbertoft direction. 6.14 At the time of writing this report, there is no time frame as to when these improvements will be completed. 2. Additionally, during evidence, the Collision Investigator recommended that the junction may benefit from the installation of “Stop” signs. One of the witnesses at the inquest stated that there had been a further accident, at the same location, around one week before the resumed inquest date. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation, 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 2"4 June 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. L8_| COPIES and PUBLICATION ! have sent a copy of my report to the Chief Coroner and to the following Interested Persons:-. Wife of Darryl representing Ageas Insurance, insurers of Darryl Souza Similarly, you are 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. [DATE] [SIGNED BY CORONER] 9 April 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.
Northamptonshire County Council Coroner for the County of Northampton Constabulary Block Angel Square Angel Street Northampton NN1 1ED For the attention of Mr H Shah Assistant Coroner 11th May, 2018. Dear Mr Shah Regulation 28 letter to prevent future deaths (Darryl Alfred Wayne Rego SOUZA - deceased) Clipston Crossroads Northamptonshire Thank you for your letter, dated 9th April 2018, regarding road safety concerns at Clipston crossroads and with specific reference to the collision on the 7th October 2018, where a male motorcycle rider, Mr Souza, tragically suffered fatal injuries. The information in your report is most helpful in terms of understanding the events that sadly led to this collision and how we, as a local highway authority, can address any particular safety concerns. In terms of context, the Clipston crossroads arrangement is a typical rural configuration found regularly across the UK road network where bends, undulations and vegetation often limit or vary the degree of visibility on the approaches. Advance warning signs and road markings are the most commonly used measures to alert motorists in all directions of travel. Furthermore, the minor junctions are generally controlled by ‘Give Way’ signs and road markings which place an onus on motorists to approach with caution reinforced by an additional requirement in law that precedence is given to vehicles travelling on the main carriageway. Department for Transport statistics from police collision records have established that the most common causation factors at rural junctions and crossroads involve motorists failing to look or judge the path, or speed, of oncoming vehicles. Angel Square Angel Street Northampton NN1 1ED Soon after the incident our engineering experts attended this particular location and carried out a study of the minor road approach from Sibbertoft (from where Mr Souza emerged just prior to the collision). The current ‘Give Way’ road markings and signage are of regulatory standard. However, a scheme involving the implementation of ‘yellow backed’ signs and refreshed lines is now planned in order to provide an enhanced reminder for inattentive motorists to emphasise the presence of the crossroads and to approach with caution. In order to supplement the signage we will also be introducing a sequence of ‘rumble strips’ in advance of the junction mouth. Due to the close proximity of a nearby dwelling these will be ‘inaudible’ transverse lines placed across the running lane which create significant optical feedback and prompt greater levels of concentration on the approach to a transition in the road. Taking account of the recommendation in your report for the junction to be regulated by ‘Stop’ signs rather than the current ‘Give Way’ controls, our engineering experts have revisited the location to investigate the feasibility of a re-grade. This type of measure is governed by national guidelines and generally confined to junctions where, in the main, visibility is severely hampered. Our experts measured an available view of 95 metres to the left from the junction mouth. This is on the margins of intervention levels but will consequently provide justification for conversion to a ‘Stop’ requirement. We will therefore include this modification in the scheme. Furthermore, the opposing junction is similar in nature and characteristic in terms of available views and the obvious requirement to exercise care. It therefore makes sense to implement an identical scheme and provide a degree of consistency for motorists approaching the main carriageway in either direction of travel. The safe implementation of the proposed measures will require road closures but we have dispensation to incorporate the scheme into our programme as soon as possible and we are therefore currently looking to complete this work before the end of June 2018. I hope these measures provide reassurance that we do take seriously issues of road safety on the county network and are ever mindful that one death on our roads is one too many. Sadly, we know that behind each statistic is a grieving family or someone coming to terms with a life-changing injury. Yours sincerely Head of Transport and Highways Northamptonshire County Council
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