Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0138, written 8 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2018 |
|---|---|
| Reference | 2018-0138 |
| Deceased | Darren Trewin |
| Coroner | John Tomalin |
| Coroner area | Exeter and Greater Devon |
| 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.
ANNEX A 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, Acting C.O. Highways Infrastructure Development and Waste Devon Highways Luckham House County Hall Topsham Road Exeter CORONER lam John Geoffrey Tomalin, assistant coroner, for the coroner area of Exeter and Greater Devon. ol) 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 9" February 2017 | commenced an investigation into the death of Darren Richard Trewin, age 49 years. The investigation concluded at the end of the Inquest on the 25"" April 2018, the conclusion of the Inquest was Mr Trewin died as a result of a Road Traffic Collision contributed to by water flowing across the A30 carriageway from a blocked drain on the central reservation. The Pathologist gave the medical cause of death as “1(a) Head Injuries with Airway Compromise”. CIRCUMSTANCES OF THE DEATH On the 31° January 2017 Mr Trewin was driving a Mercedes SLK motor vehicle belonging to his partner, who was his passenger. He was driving along the A30 Southbound when approximately % mile west of Sourton Cross near Okehampton, Devon. The car ran into a stream of water running from right to left across the carriageway from a partially blocked drain on the central reservation. This initial loss of traction, together with driver input to control the car resulted in the car leaving the carriageway at a point when it collided with the concrete anchor at the start of a barrier on the nearside of lane one, resulting in the car turning over landing upside down in woodland where the branch of a tree entered the cabin causing fatal injuries to Mr Trewin. 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) The drain in the central reservation was partially blocked with detritus washed from the road. The drain therefore could not take all the water from the heavy rain showers resulting in the water cascading across the carriageway contributing to the collision. Highways engineers who attended the Inquest were of the view that the grating on the drain should be changed to capture more water and the drains inspected more frequently and an additional drain, located above the drain that blocked should be created to assist with the capture of excess water from heavy rain. (2 To consider extending the barrier on the nearside of the carriageway to a point before the point of impact would possibly have prevented Mr Trewin’s car from leaving the carriageway and entering the woods. A longer barrier at this point, where the ground drops away to a much lower level below the carriageway, could improve safety for all drivers using the A30 at this point. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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, namely by 4" July 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: | 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 publicatjgty of your response by the Chief Coroner. 9 | [DATE] ¥D BY CORONER] 8% May 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for Exeter and Greater Devon, Mr John Tomalin of Devon County Hall, Topsham Road, Exeter, DEVON EX2 4QD in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Darren TREWIN that concluded on 25 April 2018. 1 | HIGHWAYS ENGLAND I am Mr Andrew Page-Dove, South West Regional Director for Highways England Company Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 412. 2 | CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified are as follows:— a. The drain in the central reservation of the Ago Southbound near Sourton Cross was partially blocked with detritus washed from the road. The drain could not take all the water from the heavy rain showers resulting in the water cascading across the carriageway contributing to the collision; and b. To consider extending the barrier on the nearside of the carriageway to a point before the point of impact where the ground drops away to a much lower level below the carriageway would possibly have prevented Mr Trewin’s car from leaving the carriageway. 3 | DETAILS OF ACTION TAKEN a. Drainage: Immediately after the collision we provided temporary mitigation by placing sand bags on the downhill side of the gully grating to ensure that any excess flow of rainwater was directed into the gully and away from the carriageway. The location was flagged and recorded as a flooding ‘hotspot’ immediately after the incident. This ensures that the location is subjected to a weekly inspection by Highways England (HE) inspectors. If the inspector sees any material that may have the potential to compromise the gully operation it is removed at the time if possible. If the matter cannot be dealt with by HE inspectors at the time, our service provider (Ringway Infrastructure Services Limited) is called in to undertake more substantial operations to ensure the gully operates as designed. The time period for response from the service provider is dependent upon a combination of the nature of the problem, weather conditions at the time and the immediate weather forecast. An additional gully has been installed adjacent to the existing gully at the end of the drainage channel to increase the efficiency of rainwater interception and prevent water from reaching the carriageway. This work was completed on 16 June 2018. This gully will be subject to the same maintenance regime as described above. b. The vehicle restraint barrier is addressed at point 4b. below. 4 | DETAILS OF FURTHER ACTION PROPOSED a. Drainage: A further gully will be installed approximately 100 metres uphill of the end of the drainage channel referred to in point 3a. above. This will further increase surface water drainage capacity and reduce the amount of water reaching the existing lower gully. This piece of work is currently in the design process and will be constructed by the end of September 2018. A wider drainage study at the location (from the top to the bottom of the hill) has commenced and is due for completion this financial year (2018/19). The study will require detailed modelling to determine if there is any other work that can be undertaken to further mitigate the risk of a similar collision. Vehicle restraint barrier: A Road Restraint Risk Assessment Process (RRRAP) is to be undertaken in the vicinity of the existing vehicle restraint by the end of September 2018. This will inform the requirement for a vehicle restraint barrier at the location in line with current standards, Dependent upon the outcome, we will implement a scheme to introduce a vehicle restraint barrier that reflects the risk assessment findings. — DATE 5 | TIMETABLE FOR ACTION ACTION 16-06-18 Install additional gully adjacent to existing gully 30-09-18 Install additional gully 100m upstream of existing gully 30-09-18 Undertake Road Restraint Risk Assessment (RRRAP) 31-03-19 Complete a wider drainage study 31-03-19 Act upon the outcome of the RRRAP to include design, construction, and/ or modification of the existing vehicle restraint barrier (if appropriate). 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 action planned and underway is in this light to help to prevent future-deaths at this location. 7 Date: 2a/e [cg Signed: Ak y, Regional Director on behalf of Jim O'Sullivan
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