Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0281, written 13 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Aug 2018 |
|---|---|
| Reference | 2018-0281 |
| Deceased | Nana Boateng |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner
for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
.
Director of Highways & Transport
Wiltshire Council
County Hall
Trowbridge
BA14 8JJ
1
CORONER
I am David Ridley, Senior Coroner for Wiltshire and Swindon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 4 January 2018 I commenced an investigation into the death of Nana Kwabena Boansi
BOATENG and an Inquest into his death was opened by me on the 12 January 2018. On the
9 August 2018 I concluded Nana’s Inquest. I found that the medical cause of death was
1a) Chest Trauma with Haemorrhage 1b) Road Traffic Collision. In box 3 of the Record of
Inquest I recorded how, when and where Nana came by his death as follows:-
Nana was confirmed as having died at the scene at 0425 on 24 December 2017 as a
result of having sustained a chest trauma with haemorrhage when his Ford Fiesta motor
car collided with a DAF Light Goods Vehicle travelling in the opposite direction on a left-
hand bend on the A429 heading south towards Lower Stanton St Quintin in Wiltshire
(OS ref ST 911 817). It is unclear as to why Nana had been on the opposite side of the
highway (restricted by worn road markings) and he was attempting to return to the
correct side of the highway when the collision occurred. Nana had been drinking
alcohol (96mg/dl blood alcohol) prior to the incident and this more likely than not was a
contributory factor in the collision occurring.
Consistent with what I recorded elsewhere on the Record of Inquest as a conclusion I recorded –
Road Traffic Collision.
4
5
CIRCUMSTANCES OF THE DEATH
See box 3 above
CORONER’S CONCERNS
During the course of the inquest the evidence I had been provided with a copy of a collision
investigation report prepared by
regard to a number of photographs but in particular I noted a photograph that appeared on page
29 of 39 of his report which showed the approach to the left hand bend where the incident took
place at night. As part of any road traffic Inquest I use Google Earth and in particular the “street
view” function in order to get a feel for the location where the incident took place. I have
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
of Wiltshire Constabulary. In the report I had
included with this report three additional pictures of the location that have been lifted from
Google Earth. The imagery was as at May 2017 according to the web browser which of course
was some seven months prior to Nana’s death. The photographs show the northern approach to
the left-hand bend which is exactly the same path that Nana would have been travelling on that
Christmas Eve morning. Whilst the state of the road surface appears to be in good condition
what is not in good condition are the road markings. It is clear from the first picture that this
section of road being a sharp left-hand bend travelling south is subject to no overtaking
restrictions in both directions. Looking at the photographs the white lines that should be present
in the centre of the highway have been significantly worn away to the extent that immediately
approaching the left-hand bend they are non-existent. I was informed and as can be seen from
the photograph in the police collision report, the cats eyes are also not in working condition.
I appreciate that one should drive at a speed relative to the road conditions but in this instance, it
is clear from the photographs that the road markings effectively suddenly disappear as a result of
road wear. Whilst I was not able to make a finding on a balance of probabilities that the absence
and the poor state of these central road markings more likely than not contributed to Nana losing
positional awareness on the highway and crossing onto the opposite side of the highway where
upon a collision then ensued as he attempted to return to his side of the highway, it does remain
a possibility hence this report.
I am sure you will appreciate road markings provide not only guidance to road users so that they
can position their vehicle accordingly on the public highway but also serve to provide information
to road users, as in this case, that this section of highway was subject to no overtaking in both
directions. I would ask in view of this report that you urgently review this section of highway as
its current state in terms of road markings is of great concern to me.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
13 October 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 Person,
sister of Nana Boateng.
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.
9
Dated 13 August 2018
Signature_________________________
Assistant Coroner for Wiltshire & Swindon
On behalf of David Ridley, Senior Coroner for Wiltshire & Swindon
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
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.
Wiltshire Council Where everybody matters County Hall Bythesea Road Trowbridge Wiltshire BA14 8JD 13th September 2018 Mr David Ridley Senior Coroner 26 Endless Street Salisbury SP1 1DP Dear Mr Ridley Nana Kwabena Boansi Boateng - Deceased A429 at Hullavington Thank you for your recent Regulation 28 Report in relation to the above. I have carefully considered the contents of your report and the suggestions made. I would firstly advise that there is no obligation upon Highway Authority’s in the United Kingdom to provide any road markings, be this centre lines, edge lines or any other markings. It is for the driver to adjust their driving style to the conditions that are encountered and drive appropriately. However, it is recognised that road markings can play a significant role in the overall efficiency and safety of the highway network. Unfortunately, due to funding shortfalls in recent years there has been a deterioration of road marking condition on many roads nationally. This has been recognised in Wiltshire and funding has been allocated to address this in the current highways budgets. As such I have arranged for the relaying of the road markings on the bend and this work should be completed by the end of October. Yours sincerely Director, H i g h w a y s and Transport Tel: 0300 456 0100 www.wiltshire.gov.uk facebook.com/WiltshireCouncil ©wiltscouncil
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