Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0163, written 25 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 | 25 May 2018 |
|---|---|
| Reference | 2018-0163 |
| Deceased | Neil Jones |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Alcohol, drug and medication related deaths · 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 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. Chief Executive - Warwickshire County Council nn CORONER lam S McGovern, senior coroner, for the coroner area of Warwickshire CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule §, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2073. INVESTIGATION and INQUEST On 18 December 2017 | commenced an investigation into the death of Neil JONES 26 years old. The investigation concluded at the end of the inquest on 25 May 2018. The conclusion of the inquest was that Mr Jones died as the result of a Road Traffic Collision CIRCUMSTANCES OF THE DEATH Mr Jones was attended the Bel Air nightclub at the Belfry Resort. He was ejected from the nightclub due to his intoxicated condition. He was hit by vehicle at about 1.30am on the A446 outside the Belfry Resort. 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 wilt 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) There have been 4 (four) fatal road traffic collisions at this site over 10 years despite a reduction in the speed limit to 50 mph.in 2008.1 am aware that the site is being considered as a casualty reduction scheme although [ understand no final decision has been made. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Chief Executive of Warwickshire County Council have the power to take such action. YOUR RESPONSE |__| Senior Coroner § McGovern 3 WA Cyven. You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 July 2018. f, 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 (2) EE rncther) (b§Erartner) & (c) Belfry Hotel & Resort fam 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 usefui 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. 25 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.
Warwickshire County Council Legal Services Shire Hall, Warwick, CV34 4RL DX 723362 Warwick 5 Mr Sean McGovern Senior Coroner 24th July 2018 Dear Mr McGovern I am writing in response to the concerns raised by your investigation and report of 1st May 2018 into the death of Mr Neil Jones. Mr Jones died as a result of a road traffic collision which occurred on 16th December 2017 during the hours of darkness on the A446 Lichfield Rd, Wishaw near the Belfry hotel. Our understanding is that excessive speed and lighting were not given as causative factors. The County Council has carefully considered your report and the matters of concern raised in it, specifically that there have been 4 fatal collisions at this site over 10 years despite a reduction in the speed limit to 50 mph in 2008. Notification of the collision was received by the County Council on 18th December 2017. Following this notification Lee Williams a Road Safety Engineer, from the Traffic and Road Safety Group attended the site with Rod Lake, the traffic Management Assistant from Warwickshire and West Mercia Police’s Road Safety Team. This site visit is a normal procedure following any fatal road accident. The purpose of the site visit is to ascertain whether for safety reasons there are any immediate actions that need to be taken in respect to the highway and any possible defects and/or improvements that should be remedied or carried out without delay. At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken. The County Council addresses road safety in a number of ways. In the case of this length of road, the relevant programme is the casualty reduction programme. We undertake an annual review of all collision cluster sites and routes across the County in order to identify those with the worst collision records and where there is a pattern of causes which can be addressed by engineering measures. The number of possible schemes considered each year across the County exceeds the annual funding available for the programme and, therefore, it is necessary to prioritise schemes according to objective criteria. The criteria identify those schemes which will deliver the greatest reduction in casualties for the money spent. Lexcet Practice .‘Mnagetrent Standard Law Society Accredited Printed on 100% recycled paper As part of the annual casualty reduction scheme analysis, the review of the A446 Lichfield Road revealed that there had been 36 collisions within a 5 year period, of which 12 were serious and 4 fatal. 4 of the 36 accidents occurred during the hours of darkness. One of the fatal accidents was comparable to the death of Mr Jones in that it involved a pedestrian affected by intoxication being struck by a vehicle at night. The death of Mr Jones increases the number of casualties on this length of the A444 and thus will affect the prioritisation of schemes. However, until we have completed our scheme short listing process it is not possible to commit to any scheme. Given that the resources available are finite, any decision to implement one scheme will mean that one or more other schemes cannot be implemented elsewhere. Therefore, it is important that the prioritisation process is adhered to before committing funds to a scheme. We are currently undertaking this process and would expect to make a decision by the end of September at which point we will be able to confirm the outcome. Options for consideration should a casualty reduction scheme be prioritised at this location could include extending the 50 mph limit over the whole length of the A444 from Bassetts Polo to the A4091 roundabout and introducing average speed cameras to enforce the limit. In addition to enforcing speed limits, average speed cameras can encourage vehicles to travel at more regular and consistent speeds and that can help other road users judge their speed better. However the final design of any scheme introduced would be dependent upon more detailed work that would be required along the stretch of the highway concerned. The County Council has taken very seriously your report and the concerns raised in it. I do hope that through this letter both you, and the family of Mr Jones, can he assured of the County Council’s commitment to casualty reduction schemes and to reducing the number of tragedies on the county’s highways in the fuluie. Yours sincerely
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