Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0108, written 18 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 | 18 Apr 2018 |
|---|---|
| Reference | 2018-0108 |
| Deceased | Harry Jellicoe |
| Coroner | Paul Smith |
| Coroner area | Lincolnshire |
| 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
HM SENIOR CORONER
‘Lincolnshire
THIS REPORT IS BEING SENT TO: | .
1. Highways Department Lincolnshire County Council
Nv]
CORONER
| am Paul Duncan Smith, Area Coroner for the Coroner Area of Lincolnshire, 4 Lindum Road
Lincoln LN2 1NN
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 cnet (Investigations) Regulations 2013.
http: legislation.gov.uk/uk S/schedul raph/7
http://www legislation.gov. uiakei201 3/1629/part/7/made
CIRCUMSTANCES OF THE DEATH
INVESTIGATION and INQUEST
On 28 October 2016 | commenced an investigation into the death of Harry James Jellicoe aged 26.
The investigation concluded at the end of the inquest on 27 March 2018. The conclusion of the
inquest was that Mr Jellicoe died as a result of a Road Traffic Collision, the medical cause of death
being:
1a. Traumatic Brain Injury
2. Rib Fractures and Lung Contusions
1. On 16 October 2016 Mr Jellicoe was driving his MG TF motor car, registered number
YT 03 OSU eastbound on the A151 road between Colsterworth and Corby Glen,
Lincolnshire. Although not raining at the time, it had previously tained heavily and the road
surface was wet.
2. Shortly before reaching Corby Glen Mr Jellicoe reached a point at which the road passed
underneath a bridge carrying a railway line.
3. Mr Jellicoe drove underneath the bridge. The road turned to his right at an angle of over 30
degrees and began to climb uphill. As Mr Jellicoe followed the road, he lost control of his
vehicle which left the carriageway to the nearside, suffering a heavy impact with a roadside:
tree. Mr Jelilcoe suffered severe injuries from which he died In hospital some days later.
4. Mr Jellicoe had purchased his vehicle from a reputable garage earlier in the year. It had
been subject to an MOT test on 17" June 2016 and had been given a certificate. No
advisory matters were raised at that time.
5. Despite that history, the vehicle was found to have front tyres which were each extensively
worn and displaying significantly less than the legal minimum depth.of tread required.
Evidence was received that the pattern of wear was Ilkely to have resulted from a
longstanding misalignment of a steering or suspension component within the vehicte.
6. The cause of the loss of control and consequent road traffic collision was found to be a
combination of the speed at which the vehicle was driven, the wet road conditions
prevailing at the time and the lack of tread on the front tyres which arose from the manner
in which the vehicle had been set up.
| 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. —
(ly The section of road where this incident occurred is subject tono specific speed restriction.
The national speed limit applied.
(ll) The nature of the bridge construction imposes a height restriction on vehicles passing
underneath of 4.6m (15 Feet 3 Inches).
(Il) The arch of the bridge is such that the full height Is only avallable to vehicles using the
centre of the carriageway. The bridge properly bears clear signage advising of that risk
and guiding high sided vehicies towards the centre of the carriageway.
{IV) | received evidence that on both approaches to the bridge there is clear signage warning
drivers of the existence of the bridge and its height restriction, and advising high sided
vehicles to utilise the centre of the available carrlageway.
(V) Although traffic approaching from the West has a clear view of the bridge for some —
considerable distance, the nature of the landscape is such that it Is not possible to see any
significant distance beyond the bridge arch to identify traffic, especially high sided vehicles
which may be occupying the centre of the carrlageway, approaching from the East.
(VI) Similarly, and for the same reasons, traffic approaching from the East has a much reduced
view of the approach to the bridge and cannot identify traffic approaching from the West.
(VII) In light of the current signage and proper recommendation that high sided vehicles utilise
the centre of the carriageway, given the restricted line of vision through ‘the bridge arch,
you may feel that the current speed limit is too high and requires revision. Likewise, there
Is no signage Indicating priority of passage where high sided vehicles are required to utilise
the full carriageway.
(Vill) Whilst | received evidence that there have been very few reported collisions involving
HGV's at this location, there was a clear consensus among the local drivers who gave
evidence that this location posed a significant potential hazard, for the reasons given
above, particularly for those motorists who were not famlliar with the area.
6.
| 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
13 June 2018. I, the Coroner, may extend the period.
Your response must contain detalls 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
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
a
| 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.
P D Smith
Area Coroner
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